Harlingen Family Dentistry Wins Major, Precedent-Setting Decision in Texas Medicaid Orthodontics Case

HHSC Administrative Judge confirms Office of Inspector General (OIG) expert not credible and that no evidence of fraud or misrepresentation is to be found in practice’s Medicaid orthodontic billings

Harlingen, Texas: The Administrative Law Appeals Division of the Texas Health and Human Services Commission has confirmed no evidence has been shown that the billings for orthodontic treatment of thousands of Medicaid-eligible children in south Texas made by Harlingen Family Dentistry (HFD) from 2008 to 2011 contain fraud or misrepresentation (SOAH Docket No. 529-13-3180 Harlingen Family Dentistry vs. Texas Health and Human Services Commission). The Texas Tribune had named HFD as the state’s 17th top billing clinic for Medicaid orthodontic claims in 2010-2011.

HHSC Administrative Law judge Susan Fekety upheld a proposal for decision by the State Office of Administrative Hearings that found:

  1. Investigation of HFD was based solely upon its status as a top 25 biller of Medicaid for orthodontia and that no actual complaint against HFD had been filed.
  2. That the Texas Medicaid and Health Partnership (TMHP), the private sector contractor of HHSC, which had pre-approved all HFD applications for Medicaid orthodontic treatment, was known by both HHSC and OIG to have inadequate numbers of trained dental staff to properly review orthodontic applications. This situation was discovered by an OIG audit of TMHP in 2008. At the time, HHSC did nothing to remedy it because it would require a change to TMHP’s contract.
  3. After reviewing all evidence, there was no evidence of Medicaid fraud or misrepresentation by HFD dentists billing for orthodontic services.
  4. The orthodontic expert hired by OIG was not credible in his review of cases and finding that 84 out of 85 cases he reviewed did not qualify for Medicaid funding under then-current guidelines.
  5. That the Texas Medicaid HLD scoring index, used to grade the severity of orthodontic cases, was vague and subjective rather than clear cut and unequivocal as OIG had represented.

“I am extremely pleased that the judge saw the truth of the matter about the integrity of our services and our dentists,” stated Dr. Juan D. Villarreal, owner of Harlingen Family Dentistry and a former member of the Texas Board of Dental Examiners who had been selected by Governor Perry in 2001. “I am afraid to say that it appears that honest dentists are being ‘gamed’ rather than the other way around so the state can try to collect back funds its contractor had pre-approved years ago and that they want to claw back regardless of consequences to providers and patients. It just shows how broken Medicaid really has become.”

The case was initially brought to SOHA late last year by Dr. Villarreal as OIG had instituted a 40% payment hold last September against HFD’s total on-going Medicaid billings. OIG alleged that there were credible allegations of fraud based on their expert’s review of 85 of 160 some case records which OIG had confiscated from HFD’s offices last July. He determined that 84 out of 85 cases should not have been funded.

In making the case before SOHA, HFD hired their own expert witness who also reviewed the same 85 cases. He found that he would not have approved eight of the 85 cases in a matter of professional disagreement with the attending dentists. Consequently, Judge Kilgore reduced HFD’s payment hold to 4% from 40% of Medicaid billings until resolution of the overpayment issue.

“While we are not pleased that a payment hold continues and that our money for services earned is still tied up, we have shown that the public perception of dentistry has been needlessly tarnished by the preposterous allegations that Texas Medicaid orthodontic providers conspired en masse to defraud the government.

“A recent survey of Texas dentists shows that 93% of those who take Medicaid do so for altruistic reasons, to give back to the community and help impoverished children and families, not for money. This whole debacle has hurt the patients we are trying most to help and warned dental providers off from helping them,” concluded Dr. Villarreal.

1 ~ Interactive: Challenges in Texas’ Medicaid Dental System

Dr. Juan D. Villarreal
Harlingen Family Dentistry
(956) 428-5322
Tony Canales, Attorney
Canales & Simonson, P.C.
(361) 883-0601

Brief Summary of Situation with Texas Medicaid and Harlingen Family Dentistry
(1) State Office of Administrative Hearings decision in the HFD case
(2) THHSC’s Exceptions to Proposal for Decision (2) THHSC’s Exceptions to Proposal for Decision
(3) State Office of Administrative Hearings final order (3) State Office of Administrative Hearings final order
(4) Texas HHSC Final Order in the case (4) Texas HHSC Final Order in the case

Leave a Reply

Your email address will not be published. Required fields are marked *