The Washington Attorney General’s Office lauded its 2015 recovery of $3.35 million on behalf of state taxpayers and the state Medicaid program. In today’s case, we explore a 2015 recovery involving the nearly decade-long overbilling scheme alleged to have been perpetrated by a Seattle-area dentists’ office regularly treating both pediatric and adult Medicaid enrollees. According to the allegations, the center regularly unbundled certain routine dental care services in favor of having patients return for a separate appointment with a dental hygienist or dentist, at an increased rate, for medically unnecessary procedures and dental treatments.
Details of the case against Sea Mar Health Center
The Sea Mar Health Center, which maintains several offices in the Seattle area, regularly treats Medicaid enrollees by offering routine dental care, check-ups, and other necessary services covered by state and federal healthcare programs. As you are likely aware, Medicaid is funded by both the state and federal governments, with each contributing money to help ensure underserved populations receive the care they need. However, these programs are often stretched to the limit financially and agencies like Washington’s fraud unit are tasked with ensuring the funds are used solely for medically necessary procedures and medical needs.
According to the allegations, the Sea Mar Health Center unbundled its typical six- or twelve-month check-ups, requiring patients to return to the office for procedures like a fluoride rinse – which is easily performed by a dental assistant and traditionally included as part of a regular check-up. The allegations against Sea Mar reveal that instead of charging the typical allowance for a fluoride treatment, which is $13.25 for pediatric patients and $23.41 for adults, Sea Mar asked patients to return on a separate day to allow for the treatments to be administered by a hygienist or dentist – often at a rate of $180.00 per visit. This scheme runs afoul of Medicaid rules, which only allow offices to bill at the hygienist or dentist rate if medically necessary. Allegations also reveal that Sea Mar regularly exceeded the number of examinations allowed per patient under Medicaid rules.
The case settles both state and federal concurrent False Claims Act petitions. However, the press release issued by the Washington Attorney General’s office does not reveal how the settlement proceeds are to be allocated between the two programs.
Washington Attorney General Bob Ferguson said in a statement:
“Without exception, providers who participate in our state’s Medicaid program must accurately bill for and document services provided….I’m pleased my office was able to recover the excess taxpayer funds that went out the door so this money can go back into health care for those in need.”
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