Several South Carolina children’s dental clinics are among more than 100 nationwide entering into a settlement with the Justice Department regarding false claims submitted for Medicaid payment.
Benevis, which operates Kool Smiles clinics, has agreed to pay the federal government and participating states $23.9 million in the settlement.
The government accused Benevis and Kool Smiles of submitting false claims to state Medicaid programs for medically unncessary dental services performed on children insured by Medicaid. Kool Smiles has about a dozen offices throughout South Carolina included among its 130 clinics across 17 states.
Federal prosecutors accuse the company of submitting false Medicaid claims to those states between January 2009 and December 2011. Investigators said the claims centered around pulpotomies (baby root canals), tooth extractions, and stainless steel crowns, and even seeking payment for pulpotomies that were never performed. A complaint claims Kool Smiles clinics routinely pressured and incentivized dentists to meet production goals through a system that disciplined “unproductive” dentists and awarded “productive” dentists with substantial cash bonuses based on the revenue generated by the procedures they performed. According to the government’s allegations, Kool Smiles clinics ignored complaints from their own dentists regarding overutilization.
“Billing Medicaid programs for dental procedures that are not necessary contributes to the soaring costs of healthcare,” Acting Assistant Attorney General Chad Readler of the Justice Department’s Civil Division said in a statement. “When healthcare providers put vulnerable patients at risk by performing medically unnecessary procedures to achieve financial goals, we will take action.”
A statement from Benefis says the companies disagree with the government’s allegations:
“The settlement agreement with the government does not relate to any claims regarding the quality of the dental care provided to patients. Importantly, the settlement does not include any admission or determination of wrongdoing by the companies, their employees or any Kool Smiles dentists. In fact, the companies strongly disagree with the government’s allegations. The investigation largely focused on professional disagreements between qualified dentists in determining the appropriate level and cost of the care. For perspective, the government disagreed with the care provided in less than one percent of the procedures billed during the reviewed period,” the company said in the statement.
Benevis also cited recent study which found Kool Smiles dentists provided fewer total dental services per Medicaid patient than non-Kool Smiles providers.
The companies are disappointed that reasonable disagreement between dentists can become a FCA case,” the statement continued. “However, given the seven years and significant expense already incurred, as well as the anticipated additional time and expense associated with lengthy litigation, the companies believe putting this matter behind them was the best option for their dentists, team members and the patients they serve.”