"The Medicaid and orthodontic fraud task force was convened to ensure the state had a comprehensive and coordinated response to a dramatic uptick in fraud by Medicaid providers," said Daniel Hodge, the first assistant for Attorney General Greg Abbott. "The highest levels of all affected agencies and divisions are actively involved in advancing the investigation as efficiently and effectively as possible."
John Scott, the deputy attorney general for enforcement litigation, chairs the task force, which also includes officials from the Medicaid Fraud Control Unit and Civil Medicaid Fraud Unit at the AG's office, and officials from the inspector general and other departments of the HHSC.
In 2010, Texas spent as much on orthodontic services as every other state combined, according to a report released in April by the U.S. House Committee on Oversight and Government Reform. "The state has admitted that widespread fraud was occurring and that the organization the state hired to assess prior authorization forms was essentially rubber stamping forms for approval," the report states. An orthodontist consulted by the inspector general's office at HHSC estimated that 95 percent of approved claims should have been denied, according to the report.
State officials said the task force, which was created this year, allows the agencies to take advantage of what each group brings to the table. For example, the inspector general's office has software to monitor whether a provider's claims data looks suspicious and can put payment holds on providers it suspects are committing fraud. And the AG has teams of lawyers from the two Medicaid fraud units who follow through on investigations, subpoena records and press charges.
The state is also getting an assist from whistleblowers like Dr. Morna Staffel, a pediatric dentist in Fort Worth, who said she has stacks of evidence -- in the form of patient records -- of children being overtreated and, in effect, abused by dental clinics seeking to profit off the state's dental program for low-income children.
On Monday, for example, she had to remove six teeth in a child's mouth that had abscessed less than six months after Medicaid paid for the child to be treated at a nearby dental clinic. "When I see this type of situation, I'm pulling patient records, I'm keeping patient records, I'm calling the [Office of the Inspector General]," said Staffel.
Evidence turned over to the state by whistleblowers is filed under seal. And state officials cannot disclose how many investigations they are currently pursuing. But one provider, All Smiles, which was the focus of a WFAA-TV report in October that brought the allegations of fraud into the national spotlight, appears to be in their crosshairs.
State authorities familiar with the task force's investigations said the group is committed to recovering all taxpayer funds lost to dental fraud, from both dental providers and the Texas Medicaid and Health Partnership, which was responsible for evaluating the medical necessity of dental claims and approving payment.
The state audited TMHP's process for evaluating dental claims in 2008 and recommended that the contractor increase the number of licensed dental professionals reviewing orthodontia claims, according to a State Office of Administrative Hearings report related to a recent allegation of Medicaid dental fraud. "TMHP responded to the audit's recommendation by saying that an increase in the use of dental professionals would require a change in TMHP's contract, which did not occur," the report states.
TMHP recently renewed its state contract, and state officials familiar with the investigations said they plan to work with the company on negotiations to recover state funds lost to medically unnecessary claims.
In an email to The Texas Tribune, Ken Ericson, a spokesman for TMHP, said, "Several providers are under state attorney general investigation -- and we are cooperating with that investigation."
Most of the rise in Medicaid dental claims was probably legitimate, said Stephanie Goodman, spokeswoman for HHSC, because the state had increased reimbursement rates by 50 percent to expand access to care. "Those other factors kind of masked the fact that there was also probably an increase of bad actors in the program," she said.
Texas became a target for dental fraud after 2007, when the Legislature allotted an additional $1.8 million for Medicaid children's dental services, as part of a legal settlement to increase access to care.
State authorities familiar with the task force's investigations confirmed it has found that some dental clinics have illegally solicited Medicaid patients by standing outside large retailers and grocery stores and handing out gift cards in exchange for signing up for a free dental exam. And the inspector general recently issued a statement that said, "Offering inducements to Medicaid clients is a violation of state and federal law and is subject to a penalty of up to $10,000 per violation."
As the Tribune reported in July, the crackdown on orthodontic fraud has left many patients with untended braces, and a difficult transition to Medicaid managed care has exacerbated problems with access to care. The state is currently severing ties with Delta Dental, one of three Medicaid managed care plans, in part because state officials said the company failed to establish a computer system for providers to submit claims in a timely manner. In December, 1.1 million individuals enrolled with Delta Dental will be transferred to the other two managed care dental plans.
Staffel said the transition to managed care has limited the number of orthodontists willing to take referrals for Medicaid patients, and many patients have been left "hanging in limbo," after the state shut down their orthodontic clinic by withholding Medicaid payments while the state investigates allegations of fraud.
HHSC has informed orthodontic providers that the dental board can suspend or revoke their license for abandoning Medicaid patients.
"We've worked really closely with the dental board on that issue," said Goodman, adding many orthodontists have also stepped up to help address the problem with access to care. "Even providers that didn't normally take Medicaid patients have agreed to take a few."
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This article originally appeared in The Texas Tribune at http://www.texastribune.org/texas-health-resources/medicaid/joint-task-force-tackles-medicaid-dental-fraud/.