Brace Yourself

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18237674 - doctor

Medicaid not only provides affordable medical coverage to adults, children, pregnant women, low-income families, and elderly and disabled individuals, but also dental and orthodontic treatment to eligible beneficiaries. Read on to find out how a New York orthodontist with 12 locations in Manhattan, Brooklyn, Queens, The Bronx and Staten Island, plus locations in Nassau and Rockland Counties carried out a Medicaid fraud scam that stole millions of dollars from the state and federally-funded government healthcare assistance program. (The pain level could be likened to having your braces tightened nine million times. Ouch!)

Medicaid usually covers children 21 and under for orthodontic needs that are “medically necessary.” Considering that the average cost of braces can total up to around $5,500 per person, you can figure that the $9 million settlement the chain agreed to probably impacted hundreds of children. (The fraudster at the helm of this Medicaid fraud scheme figured he could get away with employing uncertified assistants. He most likely paid them a lower rate, but billed Medicaid as if they were certified and licensed.)

Orthodontic dental assistants help implement procedures that correct alignment and spacing issues. In the State of New York, orthodontic dental assistants can work in this career field with just a high school diploma and on-the-job training, but they must also be licensed as a Certified Dental Assistant. Today’s fraudster operated the chain of 12 offices with dental assistants that were not certified. (How would you like to have someone moving your teeth around without knowing what they are doing. Why not adjust your braces yourself?) The New York-based orthodontic business submitted false bills to Medicaid claiming that certified orthodontic dental assistants had done the job.

In a settlement, the orthodontist and the company admitted that uncertified employees performed some of the intraoral procedures that were billed to Medicaid. (Even though they had told Medicaid that the employees who performed the claimed orthodontic services were qualified.) The orthodontist and the company agreed to participate in a corporate integrity agreement or use an independent monitor that will report back to the State confirming that the company is compliant with New York State law. In addition, the orthodontist and the company agreed to pay $9 million to Medicaid – $4.5 million in restitution for the deceptive actions and another $4.5 million in penalties. (That’s what I meant about the pain level of having your braces tightened nine million times.)

Fortunately, today’s orthodontist from New York confessed and agreed to make amends for leading the Medicaid fraud scam that stole millions from the state and federally-funded healthcare program. Also fortunate was that the investigation into the crime did not reveal that any patients were harmed by the uncertified and unlicensed dental assistants. (Let’s hope that the orthodontist will comply with Medicaid’s tight restrictions, ultimately ensuring that this man will walk a straight line when serving Medicaid beneficiaries in the future.)

Today’s “Fraud of the Day” is based on a press release entitled, “Attorney General James Announces $9 million Settlement With Orthodontist For Allowing Uncertified Employees To Perform Orthodontic Procedures,” released by the Office of the New York Attorney General on January 15, 2019.  

NEW YORK – Attorney General Letitia James announced today a $9 million settlement with “Diamond Braces” for allowing uncertified employees to perform orthodontic procedures and then improperly billing Medicaid for payment for such procedures. “Diamond Braces” is a chain of dental offices operating in twelve locations in New York State, including dental offices in all five boroughs and in Nassau and Rockland Counties. 

“It is unacceptable that uncertified individuals would ever perform orthodontic work in New York,” said Attorney General Letitia James. “Diamond Braces falsely billed Medicaid for these services, cheating our state out of millions of dollars. We will never tolerate these deceptive business practices that break the laws designed to keep patients safe.”

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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.