Though most Medicaid dental providers do honest and ethical work, Medicaid fraud is one of the most lucrative business models in U.S. dentistry, according to a report published Nov. 5 in the Journal of Insurance Fraud in America.
Author Michael Davis, DDS, argues that much of the fraud incentive stems from corporate chains that make up large segments of the Medicaid dental market.
Medicaid fraud typically consists of overtreatment, unnecessary sedation, upcoding tooth sealants to fillings or abusing so-called encounter fees.
Many outlier billings originate from large Medicaid-focused DSOs, according to HHS investigations in New York, California, Indiana and Louisiana. In New York, "almost a third of the general dentists were associated with a single dental chain that had settled lawsuits for providing services that were medically unnecessary or that failed to meet professionally recognized standards of care to children," according to a federal inspector general report cited by Dr. Davis. Another report reads, "Notably, two-thirds of the general dentists with questionable billing worked for four dental chains in Indiana. Three of these chains have been the subject of Federal and State investigations. A concentration of such providers in chains raises concerns that these chains may be encouraging their providers to perform unnecessary procedures to increase profits."
Dr. Davis concluded by urging Medicaid to install more stringent anti-fraud safeguards that typify private-sector dental insurers.