$4 Million Mistake – Dentist Didn’t Record Toothbrush Instructions to Medicaid Patients

Dr. Chad Evans of Smile Magic Dentistry in Dallas testified before the House Committee on Human Services last week regarding his experience with due process rights for Medicaid providers under SB 1803 and the HHSC Office of the Inspector General.

117 staff lost their jobs

Evans testified that his practice was placed under a 100% Medicaid payment hold by OIG .  Due to the payment hold, 117 staff had to be immediately released from their jobs to the detriment of Evan’s practice and the staff’s families. Evans told the committee members that the layoffs could have been avoided and were totally unnecessary because OIG later reduced the payment hold to only 10%.

$4 million demanded for not recording toothbrush instructions

Evans also testified that OIG was demanding repayment of monies for program violations as innocuous as not recording specific dental education instructions given to patients, such as how to hold a toothbrush, in patient files.  For this one violation, because of how OIG extrapolated program violations, the agency was seeking approximately $4 million to be returned.

The video of his testimony is on YouTube and his written remarks are below.

Good morning. My name is Dr Chad Evans; I’ve been practicing dentistry for 9 years. I worked with many of you last session to pass 1803 and thank you for allowing us to update you on the realities of how 1803 is being implemented.

I will limit my comments to three topics that I believe should be addressed in a new OIG due process bill next session: payment holds for program violations, a reliable preauthorization process, and the use of extrapolation.

For those that don’t know, program violation is a fancy term for things like paperwork mistakes. The OIG will use things as simple as paperwork mistakes or program violations to justify a payment hold.

Payment holds are devastating on a dental practice and the lives of the patients and staff. I literally had to lay off 117 individuals in a single weekend as the result of a payment hold for program violations. 117 gainfully employed Texans now on unemployment.

I’ll give you an example of the problems surrounding payment holds for program violations: According to the Medicaid provider contract I am required to provide the same offers and services to Medicaid patients as I am to the General Public. A few years ago, in order to gain more clarity on this point, my compliance officer reached out to the Texas OAGs office and was referred to Published Federal Guidelines that provided guidance on allowable office promotions.

But then Texas’ OIG put out a statement that made no allowances for any kind of promotion. This seemed to contradict both the Feds and the AG’s office. So I personally called HHSC to try to get to the bottom of it.

Here’s how that went: I called OIG and spoke to the operator, who couldn’t help me, but connected me to an OIG agent who also couldn’t help me, who transferred me to a supervisor who didn’t have a clue, who put me in touch with TMHP’s policy department, who transferred me to another supervisor. And the supervisor at TMHP recommended what? That I speak to the OIG!!!

So what was I asking that no one would answer? Is it OK to give my patients a toothbrush.

But then, despite our best proactive efforts, our practice was cited for various program violations including the one I had specifically asked the OIG about, and placed on payment hold.

Another example: if you don’t get informed consent forms for dental checkups, that’s a program violation that gets you on payment hold. It isn’t in the Board rules, and it isn’t even in the Medicaid Provider’s Manual. But it’ll get you a payment hold.

Another supposed paperwork mistake, or program violations allegedly committed, was recording in the patient file that Oral Hygiene instruction was provided but not writing down the angle the patient was told to hold the toothbrush.

A PROGRAM VIOLATION IS VERY DIFFERENT THAT AN ALLEGATION OF FRAUD. THUS, I BELIEVE THE PENALITIES SHOULD BE DIFFERENT. A PAYMENT HOLD IS NOT PROPER FOR JUST MAKING A TECHNICAL ERROR.

Back to my case. After placing the payment hold, OIG then performed what is called an extrapolation. Once they identify an alleged paperwork mistake or program violation they then allege that you made that same mistake thousands and thousands of times and extrapolate a penalty for that one mistake. In my case, they have extrapolated this one supposed mistake, what angle to hold the toothbrush, into a 4 million dollar penalty. As you can probably see, this is definitely not fraud, and I would contend it is not even an error, but that does not matter. The OIG uses its power to hold these sorts or claims over a provider’s head and extrapolate anything they view as a mistake into millions of dollars in penalties.

Finally, if HHSC or it’s agent preauthorized a medical or dental service, then the OIG should respect that preauthorization. Many dentists submitted cases to ACS/Xerox for preauthorization with all the required and requested documentation. This included a series of pictures, radiographs, tracings, and scoresheet. This material would then be reviewed by ACS/Xerox and approved or denied. If approved, the provider is then legally obligated to provide that treatment. Despite these facts, OIG has prosecuted countless providers for providing a service that was preapproved by HHSC’s agent., ACS/Xerox.

So, in conclusion, I believe the following improvements should be made to 1803:

The OIG should only be allowed to use a devastating sanction such as payment hold in instances where fraud is evident, not for simple program violations.

If the OIG is going to charge someone with a penalty, they should have to prove the material facts that form the basis of that penalty, not be allowed to extrapolate one error or mistake into millions of dollars.

Lastly, pre authorized procedures should not be eligible for sanctions or prosecution assuming no new facts are uncovered.

Thanks you for your time