Fraud and Abuse in Dentistry


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  • @goincali Dentists Anna Danieli and Patrick McKenzie at 1900 South Puget Drive, Suite 102 Renton, Wa 98055 cheated me and hurt me to get money They were not punished by law, they did not have to pay the damage. They still open the business, and they may continue cheating and hurting other patients. Any people who like to bring justice to the others please support me by finding a way to take this case to the court. Anna Danieli and Patrick McKenzie are husband and wife. They jointed other dentists advised me to extract a wrong tooth (it was not necessary to extract). First, they let the guy who cleaned my teeth recommended that I had a tooth need extracting. Then I made other appointment to see them, and then they referred me to other dentist at other place to get second opinion. All of them advised me the same thing. Later I found it was cheating. After the tooth extraction, on my last visit for cleaning teeth, they let a strange Vietnamese woman whom I had never seen before cleaned my teeth very perfunctorily. After the cleaning, this woman decided my five teeth needed filling. She said because she had been able to see by her eyes, so I should not doubt it. Then she let a Korean man (I did not know who that guy was) to check my teeth very perfunctorily. Then the guy offered to do an implant surgery for a new tooth to replace the extracted tooth. He said the surgery would be done at Anna Daniele's office and it would be a lower cost than at the other profession place. I never let it happen. The strange thing was, every office visit for any service: extraction, cleaning, tooth filling... I paid off at a time (I did not have a dental insurance), they gave me a receive like a receive of a small store. It was a little piece of paper and only number on it. No any words to explain the service. A receive of One Dollar Store still has a name and logo of its sore, and it shows what the customer has bought. But this dental office gave me a receive worse than it, only a few lines to print out the money I had paid, no any words at all. I cannot bring this case to the court. Some lawyers I came refused to take it for reasons: They were busy no more case to take, or they knew them, they did not want to against them. I want justice, anybody who see this notice, please help me to bring this case to the court. It is too hard to get stringent laws In this country
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  • I needed just One tooth pulled, went to closest one and i am shy and scared of the dentist and he knew it. he took ALL my upper teeth out for some unknown reason, made crappy dentures that i cant wear and took $4,000.00 from me without a blink of an eye. He's a repeat offender but No One will stop him. He's hurting people everywhere and now i'm just a monster in the mirror that won't leave the house or eat solid food. Every time he won't give anyone their records, he gets a slap on the wrist, but, even though i have a witness for every visit, pictures of everything and a letter from new doctor, no attorney wants a WIN WIN case, dr. james magee the 3rd at magee dental in winter springs florida, will destroy your life. Warning never go to him. Check out your dentist first, before they do 2 surgeries in your mouth and say they aren't an oral surgeon.... it's your fault
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Fraud and Abuse in Dentistry

  1. 1. Fraud and Abuse in Dentistry
  2. 2. Definition <ul><li>Fraud is the intentional perversion of truth in order to induce another to part with something of value, or surrender a legal right. </li></ul><ul><li>Stated another way, fraud is “making false statements or representations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist.” </li></ul><ul><li>Note: Intent based, and acting knowingly and willfully. </li></ul>
  3. 3. Types of Fraud in Dentistry <ul><li>Billing for services or products not provided </li></ul><ul><li>Billing for unnecessary services </li></ul><ul><li>Billing for services provided by unqualified or unlicensed clinical personnel </li></ul><ul><li>Knowingly billing for inadequate or substandard care. </li></ul><ul><li>Filing false claim reports </li></ul><ul><li>Misrepresenting the nature of services rendered </li></ul><ul><li>Advertising/issuing coupons/discounts that are not ‘real’ </li></ul><ul><li>Waiver of insurance co-payments </li></ul><ul><li>Soliciting/receiving or offering/paying remuneration to induce referrals </li></ul>
  4. 4. Definition <ul><li>Abuse is “any practice that, either directly or indirectly, results in unnecessary costs.” </li></ul><ul><li>Abuse is acting with knowledge, or in deliberate ignorance, or reckless disregard, of the truth or falsity of information. </li></ul>
  5. 5. Types of Abuse In Dentistry <ul><li>Failure of follow clinical guidelines or standards of care. </li></ul><ul><li>Providing unnecessary or substandard care. </li></ul><ul><li>Violation of participation agreements </li></ul><ul><li>Making false statements or representations </li></ul><ul><li>Providing insufficient documentation to support claim for reimbursement. </li></ul>
  6. 6. Moral Relevance <ul><li>When acting fraudulently or abusively, the dentist would be violating the following ‘rules’ of morality: </li></ul><ul><li>“ do not deceive” </li></ul><ul><li>“ do not cheat” </li></ul><ul><li>“ do not disobey the law </li></ul><ul><li>“ do not fail to do your duty” </li></ul>
  7. 7. What is NOT Fraud and Abuse <ul><li>Mistakes </li></ul><ul><li>Innocent Errors </li></ul><ul><li>Good faith interpretations </li></ul><ul><li>Good faith reliance on professional advice. </li></ul>
  8. 8. Consequences of Being Found Liable for Fraud and Abuse in Dentistry <ul><li>1. Criminal penalties and fines. </li></ul><ul><ul><ul><li>Fines of up to $250,000 </li></ul></ul></ul><ul><ul><ul><li>5 years in federal prison/violation </li></ul></ul></ul><ul><ul><ul><li>Life sentence for patient death </li></ul></ul></ul><ul><li>2. Civil fines </li></ul><ul><ul><ul><li>Fines of $5,000-10,000/occurrence </li></ul></ul></ul><ul><ul><ul><li>3x the amount claimed in damages </li></ul></ul></ul><ul><li>3. Administrative fines and penalties </li></ul><ul><ul><ul><li>$10,000-50,000/occurrence </li></ul></ul></ul><ul><ul><ul><li>Mandatory and permissive exclusion from practice. </li></ul></ul></ul>
  9. 9. Collateral Consequences <ul><li>Licensure issues </li></ul><ul><li>Community trust </li></ul><ul><li>Financial loss </li></ul><ul><li>Mobility </li></ul><ul><li>Office morale and spirit </li></ul><ul><li>Personal reputation </li></ul>
  10. 10. Cost of Fraud and Abuse <ul><li>Some sources estimate the dollar cost of fraud and abuse to be 10% of our health care budget. </li></ul><ul><li>This would mean approximately $200 billion of our current $2.0 trillion health care budget. </li></ul><ul><li>Dentistry’s share would be approximately $6 billion of our $60 billion component of health care spending. </li></ul>
  11. 11. Shift in Enforcement Environment <ul><li>1. Department of Justice’s #2 priority. </li></ul><ul><li>2. “Health Insurance Portability and Accountability Act of 1996” (HIPAA): </li></ul><ul><ul><ul><li>provided massive increase in funding for enforcement </li></ul></ul></ul><ul><ul><ul><li>mandated cooperation among agencies </li></ul></ul></ul><ul><ul><ul><li>expanded scope of fraud/abuse statues to cover all government payers </li></ul></ul></ul><ul><ul><ul><li>expanded jurisdiction to reach fraud/abuse against private payers. </li></ul></ul></ul>
  12. 12. Federal Resources To Fight Fraud and Abuse in Health Care <ul><li>FY 98 funding = $175.6 million </li></ul><ul><li>HIPPA requires a high level of cooperation among federal fraud fighting agencies. </li></ul><ul><li>Today, 551 US attorneys and FBI agents are dedicated to investigating and combating health care fraud; this compares to 346 in 1996 and 112 in 1992. </li></ul><ul><li>FBI handled 2,700 cases in 1998, compared to 591 in 1992. </li></ul>
  13. 13. Results of Increased Enforcement <ul><li>Since 1992, criminal fraud convictions have increased by more than 400%. </li></ul><ul><li>In 1997, the government recovered $1.2 billion in criminal fines, civil settlements, and administrative penalties. </li></ul><ul><li>$968 million was returned to the Medicare trust fund. </li></ul><ul><li>In 1997, 530 suits were filed under the False Claims act alone, generating $625 million in returned funds to the US Treasury. </li></ul>
  14. 14. Increased Enforcement (continued) <ul><li>At the end of 1998 there were 3,471 civil matters pending of which 161 had been filed during the year, an increase in one year of 200%. </li></ul><ul><li>In 1998, 3,021 individuals and entities were excluded from participation in federal health care programs--an increase of 11% from 1997 and 93% from 1996. </li></ul><ul><li>In 1998, $480 million was recovered in civil settlements, judgments, and administrative actions. </li></ul>