Know the Law as It Pertains to Medicaid for Dentistry

This guest post is brought to you by our friends and colleagues at Goldin, Peiser & Peiser, LLP, a Dallas-based accounting firm.

Our accounting firm, Goldin Peiser & Peiser, LLP holds information sessions, or Dental RoundTables, for dentists in the DFW area approximately 6 times a year. Topics have ranged from compliance, to marketing, to how to increase revenue. They are quite successful; we have a steady, loyal following with approximately the same number of guests, some new and some repeats, attend each session. However, our RoundTable on Dental Medicaid was something we had never seen before. The session “sold out” in a few days, prompting us to repeat the topic a few months later. It doesn’t take a genius to realize that the dental community is nervous about the stepped up efforts by the U.S. Department of Health and Human Services to audit dental practices for Medicaid fraud. And dentists should be concerned. Since 2010, the federal government has opened over 1000 new criminal cases and 1700 investigations, and is involved in over 900 civil investigations with an additional 1300 cases pending.

WHAT IS CONSIDERED FRAUD?

With the ever increasing focus on the dental community, it is incumbent upon all dentists to understand what is considered fraud. Below is a sample of the type actions considered fraudulent:

  • Billing for services or products not provided
  • Billing for unnecessary services
  • Billing for services provided by unqualified or unlicensed clinical personnel
  • Knowingly billing for inadequate or substandard care
  • Filing false claim reports
  • Misrepresenting the nature of services rendered
  • Advertising/issuing coupons/discounts that are not “real”
  • Waiver of insurance co-payments
  • Soliciting/receiving or offering/paying remuneration to induce referrals
  • Unbundling services
  • Failure to maintain adequate records
  • Intentional destruction or concealment of records

GOVENMENTAL STATUTES

Many are under the mistaken assumption that dentists committing fraud are mainly charged with violation of the False Claims Act. While that in and of itself is serious, the Justice Department has not stopped there. Dentists committing Medicaid fraud may be charged with violating a litany of additional statutes including:

  • Stark Act
  • Civil Monetary Penalties Law
  • Mail & Wire Fraud
  • RICO
  • Money Laundering
  • Health Insurance Portability and Accountability Act
  • Health Care Fraud
  • Kickbacks
  • Conspiracy
  • Illegal Drug Distribution
  • Operating a Continuing Criminal Enterprise
  • And more

PENALTIES

Action against a dentist may be taken even before an indictment. For example, the Attorney General has the right to suspend or withhold a dentist’s Medicare payment based only on reliable evidence of fraud. If found guilty of Medicaid fraud, dentists may face severe penalties, including tremendous fines and possible prison time:

  • The False Claims Act provides fines up to $10,000, treble damages, and up to five years in prison.
  • The Anti-Kickback provisions of the Social Security Act provide for fines of up to $25,000, and up to five years in prison.
  • Civil monetary penalties provide for fines up to $50,000 and treble damages.
  • RICO provides for prison terms of up to 20 years. Civil conviction under RICO provides for asset forfeiture.
  • The Health Insurance Portability and Accountability Act allows up to 10 years in prison, or up to 20 years if serious bodily injury results, or up to life in prison if death occurs.
  • Civil Monetary Penalties Law provides for a penalty of $10,000.00 per item or service. In addition, the provider is subject to an assessment of not more than three times the amount claimed for each item

The dentist may also be subject to expulsion from the Medicare and Medicaid programs for a period of not less than five years. In addition, the dentist runs the risk of having the State Board suspend or revoke his or her license.

Unfortunately, most dentists will have no idea they are targets of a criminal investigation. However, if you think you are under investigation it is advisable that you consult an attorney and a forensics CPA before talking to authorities or disclosing any documents.

For further information, email Erick Cutler, Partner at Goldin Peiser & Peiser, LLP or call him at 214-635-2541.

As a Partner of Goldin Peiser & Peiser, LLP, Erick Cutler focuses his tax compliance and consulting work in two main industries: Dental and Real Estate. Throughout the year he works with clients to improve the financial health of their practices/businesses.  He has vast experience in the area of cost segregation: he uncovers hidden costs outside of standard depreciation to help reduce property owners’ tax liabilities.