Purpose

To determine if six affiliated Brooklyn dentists billed Medicaid for services that were not medically necessary or were not provided. We also sought to determine if the affiliated dentists used illegal tactics to solicit Medicaid recipients. The audit covered the period January 1, 2007 through June 8, 2011.

Background

The State's Medicaid program provides health insurance to individuals who are economically disadvantaged and/or have special health care needs. For dental care, the State's Medicaid program requires care to conform to acceptable standards of quality and professional practice, but covers only essential services (not comprehensive). For the fiscal year ended March 31, 2011, Medicaid paid about $321 million for dental claims. From January 1, 2007 through June 8, 2011, Medicaid paid about $6.9 million for services claimed by the six dentists.

Key Findings

• We identified about $2.3 million in highly suspicious and possibly fraudulent claims that were submitted by the six dentists. The affiliated dentists defrauded the Medicaid program by creating false entries in medical records to support claims.
• It was not possible to perform all of the procedures the dentists billed in relation to the hours their offices were open. For example, on June 17, 2010, the dentists' two offices were open for a total of 19 hours. However, the dentists submitted claims for 198 procedures that should have taken nearly 59 hours to perform properly.
• The dentists routinely certified claims (in their own name) for services that were purportedly provided by another affiliated dentist. In addition, the dentists paid staff to recruit Medicaid recipients to their offices. These practices are prohibited by Medicaid regulations.
• We found questionable sanitary conditions at the two offices used by the dentists.
• We referred our findings to the Attorney General's Office for further investigation. In August 2012, one of the dentists pleaded guilty to multiple criminal charges (including felonies) for his conduct. The court ordered the dentist to make restitution to the State and could sentence the dentist to jail.

Key Recommendations

• Actively monitor the claims of the affiliated dentists. Deny or pend claims for excessive numbers of services (particularly within certain time intervals).
• Determine if the dentists should be allowed to participate in the Medicaid program.
• Direct the dentists to cease improper recipient solicitation practices.

Other Related Audits/Reports of Interest

Department of Health: Inappropriate Medicaid Billings for Dental Restorations (2007-S-71)

Department of Health: Inappropriate Medicaid Billings for Dental Services (2008-S-67)