A chain of clinics providing "free" medical services for kids from low income families was just fined $24-million because they ran a scam that implemented unneeded medical procedures on kids to run up Medicaid billings. Examples including performance of numerous root canals on screaming kids tied to boards which were not needed. Read and understand so you can ensure YOUR kid or friend is a victim of similar medical scam clinics in Lake County.
One of the many scams resulting in Medicaid fraud around the country is when a firm or clinic gives free or low cost "screenings" for certain maladies, then magically finds them, and tells the patient work is needed right away. Then the clinic or rolling clinic (like a traveling bus) provides the "services" and may or may not do the actual work on low income adults and kids who qualify for medicaid or they bill an employee's insurance firm. An example is doing work on an ingrown toenail, but classifying it as a more complex case, and billing insurance for $9500 for a one hour procedure. Then the clinic bills or overbills medicaid and immediately collects a check.
California is run by Democrats and their attorney supporters. In such cases, a company providing health insurance to employees could also end up paying for such overbillings if their insurance firm did not have systems to prevent invoices from such labs. BUT, as I found when I was a Corporate audit director, our firm was not legally able to even ask our insurance firm who the rolling labs were (they were well known) so we could prohibit our employees from using them. The attorneys in California had pushed through laws saying such "blacklisting" was illegal. However, if we used a more control oriented insurance company, they had internal systems to prohibit required pre-approvals from the known scammers, plus systems to identify high fraud risk services, and examine them more closely (and the clinic) before providing funding.
So, below is a story about such a chain of clinics that got caught big time, and being fined $24-million.
The lessons learned are:
- Always ask to see and approve the medical expense before the "procedure", especially at any rolling or tent clinic. If they told you that a procedure was needed, ask how much the invoice will be, and challenge anything that does not sound right.
- If you take kids to a "free screening" at a clinic, be forewarned about what a scam clinic might do to your kid as described in this article so they can bill for excessive services.
- If your insurance requires a co-pay that is a percentage of the bill, the scam clinic might say they will waive the co-pay, which is illegal per many insurance plans, and is a way to hide the excessive bill from you. This is also a BIG reason to require co-pays from all employees on a percent basis, because if they are required to pay 10%, they are much more likely to question high cost services.
- Many of these scams are practices in low income areas and focus only on people who qualify for Medicaid, because Medicaid is not as sophisticated in preventing scams. Thus if you are in a position of regulatory or law enforcement and you see a rolling clinic come to poor income areas, you might investigate them if you are allowed to do so. I audited group insurance plans for two corporations and learned enough to wince every time I see an ad for a "free clinic" or "free MRI screening systems", or even if they are low cost. In some cases, they could be scammer trolling for people who need something so they can provice exceptionally expensive services billed to Medicaid.
- Don't ever sponsor such a clinic for your community without really researching the firm's background.
- Additionally, many firms use low cost "TPA's" or third party administrators to handle self insurance plans. These firms get customers by charging less for processing health insurance claims, but they don't have any internal oversight systems to detect scammers like described below. As a consequence, your employer's HR department could brag about reducing "cost per claim" by paying only $6 per claim vs the $8 per claim from a bona fide insurance provider, but they could lose millions from scammers that overbill and don't get caught. I personally do NOT recommend TPA's unless you have a tough review of their internal methods to prevent overcharges and bogus billings.
- After reading the above, you might agree that a company without co-pays, (like the Lake County School District) and using a TPA without tough internal oversight systems to prevent scams will end up paying a lot more for medical services.
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from HEREDental company to pay $24M in federal settlement
The parent company of Small Smiles Dental Center in Irondequoit must pay $24 million, plus interest, for alleged improper or unnecessary treatment of children on Medicaid, whose bills are paid by taxpayers, under a federal settlement. That payment includes $1.15 million for New York state.
In a separate settlement to resolve unrelated improper billing issues dating back many years, the company will pay $2.3 million to New York state.
The settlements are with Forba Dental, which provides dental care to low-income children at 69 Small Smiles clinics nationwide, including Small Smiles in Syracuse and Access Dental in Albany.
Three whistleblowers will receive more than $2.4 million of the federal settlement, under provisions of the False Claims Act that permit private citizens to sue on behalf of the United States and share in any recovery, according to an announcement by the U.S. Department of Justice. The cases are in U.S. District Courts in Maryland, Virginia and South Carolina.
The settlement doesn’t mention any allegations specific to the Irondequoit clinic. But David Douglas Gardner, who previously worked as a dentist at Small Smiles in Irondequoit, served jail time and surrendered his medical license for defrauding Medicaid. He admitted in Monroe County court in May 2006 that he filed claims in 2005 for dental work he didn’t perform. Small Smiles in Irondequoit cooperated with the Gardner investigation and repaid the state $444,000, prosecutors said at the time.
Gardner said in one televised media interview that he was under pressure from the corporation to make at least $1 million a year and the way to do that was to perform multiple procedures such as root canals or crowns, some of which were unnecessary.
Gardner also said that children were routinely strapped to papoose boards to immobilize their bodies during multiple procedures and that children became so frightened and stressed that they would soak their clothing with sweat or wet or soil their pants while parents were encouraged to stay out in the waiting room. Papoose boards are allowed but only with a parent’s permission, which allegedly wasn’t given, said Wanda A. Fischer, public information officer at the state Office of the Medicaid Inspector General. The nearly two-year investigation included interviews with parents and children and reviews of dental and billing records.
The federal settlement involves 21 states and the District of Columbia, state Medicaid Inspector General James G. Sheehan announced. Federal agencies alleged that Forba Dental submitted claims for Medicaid reimbursement for baby root canals, placing crowns, administering anesthesia, performing extractions and providing fillings or sealants that were either medically unnecessary or done poorly.
The state’s 57-page agreement with Forba Dental details an oversight plan that requires the company to appoint a dental director for its New York state offices and requires prior approval from the state Office of the Medicaid Inspector General before any expansion in the state. Quarterly chart reviews by an independent organization must include any cases of more than three root canals or crowns during the same appointment.
The state agreement, termed a corporate integrity agreement, is posted at www.omig.state.ny.us.
Forba did not admit any liability, according to a statement the company posted online. The company said its Small Smiles network of associated dental clinics provided free screenings for nearly 10,000 children in 2009.
