Detecting Patterns

Surgeon picking up surgical tool from tray. Surgeon is preparing for surgery in operating room. He is in a hospital.

Fraud schemes are usually detected when a pattern becomes apparent. Such is the case for a Murfreesboro, Tennessee dentist, who continued to commit healthcare fraud for more than four years by using the same pattern of fraudulent billing practices. The dentist in today’s fraud case submitted fraudulent claims to private healthcare insurers and to TennCare, Tennessee’s Medicaid program. In all, he painfully extracted $965,448 from TennCare. (I’m sure government program officials were pretty sore about that.)

 The dentist from Murfreesboro had assistance from his former practice administrator, who helped run his dental practice in three locations. Together, they made sure private insurance companies and TennCare received bills that:

  • Showed dental work was completed or performed, when it was not.
  • Falsified dates of service to meet benefit program timelines and preauthorization requirements.
  • Claimed services were performed by a benefits program credentialed dentist, when they were not.
  • Included falsified supporting documents and fake narratives to support upcoding of claims, so the dentist could receive more money for more expensive procedures.

When the dentist was advised by insurance companies that audits were picking up on a pattern of false claims, he continued to submit bogus reports even when a criminal investigation into the company’s suspicious billing practices was initiated. (The warning didn’t stop the dentist, it only caused him to work harder to cover up his fraudulent billing practices.)

The dentist became a bit of a bully and strongly advised that his employees not question his billing practices. He also told them to lie if questioned by insurance companies. When his employees didn’t comply with his wishes, he disciplined and fired anyone who questioned him about the legality of his claims submission process. His employees were not the only people to suffer from his fraudulent behavior. His poor patients often had to wait a long time for the insurance claims to be settled before having dental work completed. (Sometimes the anxiety of waiting for a dental procedure to be performed is worse than having the procedure actually performed.)

The 51-year-old dentist from Murfreesboro was found guilty of healthcare fraud. The dentist was sentenced to 33 months in federal prison for running the scheme and must pay restitution to TennCare in the amount of $956,448. His former practice administrator and accomplice awaits her trial. Here’s hoping this fraudster has learned an important lesson. (Just like flossing teeth is considered to be good preventative dental care, stopping fraudulent billing practices is key to preventing a fraud conviction.)

Today’s “Fraud of the Day” is based on an article, Murfreesboro dentist gets 33 months in federal prison, posted on on June 7, 2019.

MURFREESBORO, TN (WSMV) – A Murfreesboro dentist was sentenced to 33 months in federal prison for running a scheme to defraud Tennessee’s healthcare benefit programs.

According to a news release, 51-year-old Richard N. Schott and his former practice administrator, Kendra Glenn, were charged in November 2018 with conspiracy to commit healthcare fraud.

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Larry Benson
Larry Benson is currently the Director of Strategic Alliances for Revenue Discovery and Recovery at LexisNexis Risk Solutions. In this role, Benson is responsible for developing partnerships for the tax and revenue and child support enforcement verticals. He focuses on embedded companies that have a need for third-party analytics to enhance their current offerings.