Texas orthodontic Medicaid approvals delayed by understaffing | Dr. Bicuspid

February 6, 2014 — Thousands of applications for orthodontic approvals under Medicaid were delayed after Texas employed a single dentist to review them.

The understaffing led to dentists, not the private company reviewing the applications, being accused of fraud for performing work that had not been authorized, according to a report by Courthouse News Service.

Seven dentists have filed complaints in Travis County Court, claiming that ACS State Healthcare violated the Dental Practice Act when it had “dental specialists,” not dentists, grant prior authorizations for orthodontic procedures, the article explained.

A lawsuit filed by Paul Dunn, DDS, accuses the company of only hiring one dentist for the process from 2004 to 2011 that considered tens of thousands of orthodontic prior authorizations.

According to Dr. Dunn, his practice was severely harmed when Texas Office of Inspector General (OIG) audits determined that “most, if not almost all” of these requests found to be medically necessary from 2009 to 2012 were not even evaluated by the company.

Fraud investigations by the OIG of the top 25 dental providers in Texas followed, causing further harm to his business because he is among them, the complaint alleges. Medicaid payments to his practice were frozen when the OIG ordered a payment hold against it. Dr. Dunn claims that the state is punishing the providers, not the company responsible for making the poorly reviewed authorizations.

Dr. Dunn’s complaint noted the cost of ongoing legal counsel and losses stemming from changes to his business. Three other lawsuits are seeking punitive damages for fraud, breach of contract, negligence, and negligent misrepresentation, the article explained.

Dr. Dunn is joined in these lawsuits by M&M Orthodontics; Scott Malone, DDS; Diana Malone, DDS; Antoine Dental Center; Harlingen Family Dentistry; and Juan Villarreal, DDS.

Texas orthodontic Medicaid approvals delayed by understaffing.

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