What triggers audits? It can be discrepancies in records, significant increases in billing, or complaints by former employees or patients. Or it can be a routine audit. In a recent case, a former employee went to the Dental Board to set forth allegations against her former dental office. That disclosure triggered action by the Dental Board (interim suspension), an Accusation and then a federal criminal case. It took five years for this to play out. In the meantime, the dentist surrendered his license in August 2013.
This recent case demonstrates what can happen in these cases. Dentist David M. Lewis of Sacramento pleaded guilty on January 11, 2016 to health care fraud for his role in defrauding the health care benefit program used by United Parcel Service (UPS) employees. Undoubtedly, this has been a long hard road for the now former dentist.
A former employee at Lewis’s dental practice for 9 years, Nichol Ramirez aka Nichol Lomack, who worked as an insurance claims manager, cooperated with the Dental Board and government. She ultimately pleaded guilty to one count of health care fraud for her part. She was interviewed by the Dental Board in December 2010 and the case went from there.
In October 2011 the Dental Board executed a search warrant at the dentist's office. The search warrant was used so that the dentist would not have advance notice and have any ability to alter or destroy the charts. After the charts and xrays were submitted for expert review, the Dental Board filed an Interim Suspension Order in February 2012 and filed an Accusation. In August 2013, Dr. Lewis surrendered his license. In February 2014, Lewis was indicted on health care fraud and conspiracy to commit health care fraud and mail fraud.
According
to court documents, beginning in late 2008 or early 2009 (after the economic recession), Dr. Lewis, a dentist
practicing in Sacramento, began targeting UPS employees for dental treatment
because their health care plan under the Northern California General Teamsters
Security Fund provided 100 percent coverage without any annual limits. Dr. Lewis' office allegedly offered cash and other incentives (Sonicare toothbrushes for example) to UPS patients for receiving dental
treatment or for recruiting other UPS employees to receive such treatment.
In
some instances, Dr. Lewis' office submitted claims to Delta Health Systems,
which administered the UPS health care plan, that billed the plan for
work that was never performed. In other instances, it was alleged that Dr. Lewis performed
unnecessary dental work on UPS employees, including root canals, and claims
were submitted to Delta for payment for these unnecessary services.
As part of this, the government alleged that Dr. Lewis
created false narratives for dental work that was not performed or created
false statements about purported pre-existing dental conditions to justify the
work performed. In some instances, Dr. Lewis drilled into teeth to install
temporary filings and instructed his assistants to take X-rays of the temporary
filings. Dr. Lewis' office then submitted claims to Delta with X-rays of the temporary
fillings, falsely claiming that the X‑rays depicted tooth decay justifying
further restorative procedures. The
total loss associated with Dr. Lewis’s office billing for these false claims will be determined and the government contends it may be as high as $1
million.
Dr. Lewis
is scheduled to be sentenced by United States District Judge Morrison C.
England Jr. on March 31, 2016, and employee Lomack is scheduled to be sentenced on
September 1, 2016. While both Lewis and Lomack face a maximum statutory penalty of 10
years in prison and a fine of $250,000 or twice the gross loss or gain of the
scheme, the actual sentence will be determined by the court after consideration of any applicable statutory factors and the
Federal Sentencing Guidelines, which take into account a number of variables.
Attorney Commentary: These cases are investigated at the early stages by audits by Delta Dental or other insurance carriers. It is critical that the audits be handled professionally and with an understanding that anything said by employees or the dentists is considered evidence. In addition, if there are past billing issues, the best time to correct them is immediately in order to minimize the risk of future audits.
Compliance is critical and it is never too late to cease business practices that pose risks. In today's world, the risk of losing one's professional license and facing federal or state criminal charges are not worth the short term benefits. Patients with terrific dental or health insurance benefits can be tempting for providers or their staff but long term risks need to be realistically assessed.
Posted by Tracy Green, Esq.
Ofifce: 213-233-2260
Attorney Commentary: These cases are investigated at the early stages by audits by Delta Dental or other insurance carriers. It is critical that the audits be handled professionally and with an understanding that anything said by employees or the dentists is considered evidence. In addition, if there are past billing issues, the best time to correct them is immediately in order to minimize the risk of future audits.
Compliance is critical and it is never too late to cease business practices that pose risks. In today's world, the risk of losing one's professional license and facing federal or state criminal charges are not worth the short term benefits. Patients with terrific dental or health insurance benefits can be tempting for providers or their staff but long term risks need to be realistically assessed.
Posted by Tracy Green, Esq.
Ofifce: 213-233-2260
