In every state, Medicaid covers comprehensive dental services for all enrolled children. Additionally, almost every state Medicaid program provides emergency dental services to enrolled adults. About two-thirds of the state Medicaid programs additionally cover at least some non-emergency dental services for enrolled adults. See id.
Whistleblowers play a central role in defending the Medicaid system from fraud and ensuring that the limited Medicaid funds available for dental services are effectively allocated. Whistleblowers also protect patients from unnecessary dental services by providers who prioritize profits over patients.
If you discover dental Medicaid fraud, there are multiple ways you can take action.
Reporting Dentist Medicaid Fraud Internally
If you are currently employed by a dentist, you could report Medicaid fraud to your supervisor, a human resources manager, a compliance officer, or an internal fraud hotline. Your employer may have specific internal procedures for reporting fraud, so be sure to follow those where applicable.
Reporting Dentist Medicaid Fraud to the Government
For information about reporting dentist Medicaid fraud to the government, see the Centers for Medicare & Medicaid Services’ (“CMS”) website.
CMS advise anyone who suspects fraud to first report it to the appropriate State Medicaid Agency (“SMA”). CMS published a useful list containing contact information (as of February 2014) for each SMA and each state’s Medicaid Fraud Control Unit (“MFCU”).
Contact information for reporting fraud can also be found on CMS’ State Contacts Database.
CMS also recommend contacting the Office of Inspector General’s (“OIG”) National Fraud Hotline by calling 1-800-HHS-TIPS or visiting the OIG website.
Reporting Dentist Medicaid Fraud Under the False Claims Act
Fraudulent conduct involving false claims to Medicaid can trigger liability under the federal False Claims Act (“FCA”). See 31 U.S.C. §§ 3729, et seq. For example, a dentist who submits claims to Medicaid for unnecessary dental treatments, uses substandard equipment or treatment methods on patients covered by Medicaid in order to pocket some of the Medicaid funds, or requests Medicaid payments for dental services not actually provided, is subject to FCA liability. An FCA lawsuit against a dental provider involving allegations of dental Medicaid fraud recently led to a $23.9 million recovery.
Under the FCA, a dental provider who submits a false claim for Medicaid payment is liable for three times the total cost of the fraud to the federal government, along with a civil penalty between $5,000 and $10,000. Id. § 3729(a)(1).
The FCA rewards whistleblowers who provide evidence of Medicaid fraud to the government with between 15% and 25% of any recovery if the government proceeds with the case, or between 25% and 30% of any recovery if the government allows the whistleblower to independently pursue the case. Id. § 3729(d)(1)–(2).
Since Medicaid is jointly funded by both the state and federal governments, dental services providers who commit fraud may also be liable to the state government under a state false claims act. Like the FCA, most state false claims acts allow the government to recoup triple the amount of damages from the defendant, and entitle the whistleblower to a share of the recovery.
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