Posted and filed under Dental, Fraud, FWA.

This week’s Fraud Spotlight features guest contributor Mark R. Brengelman, JD, MA. Be sure to tune into the column for more expert insights from our network of providers, investigators, and fraud experts.

This article rounds out lessons in dental misconduct involving fraudulent billing, medical records forgery/lack of documentation, and standard of care from a case in real life. Prior articles have covered how each of these kinds of misconduct can be found separately or together to discipline the license to practice dentistry issued by a state board of dentistry. Dental fraud is more than money, but how can this all come about from a case in real life? As the cliché states, life can be stranger than fiction.

Let’s take the case of Dr. S.A. This was a young dentist fresh out of dental school who had uncommon academic issues. Have you ever heard of someone pulling strings and using favors to get into school? This person used special contacts and called in favors to get out of dental school. 

After having marginal academic performance and after having to repeat a year of school with remedial training (in place of flunking out), Dr. S.A. used favors to get out of dental school with a degree. Dr. S.A. was given a rare second chance having avoided flunking out.

Having then gone into a high-volume, high-pressure dental office owned by a corporate entity, Dr. S.A. was under tremendous strain to begin paying back all those dental school student loans – having paid for five years to be in a four-year dental school program.

After several complaints were filed with and investigated by the board of dentistry, the board invoked its emergency powers and issued an immediate, temporary suspension of the dental license – effectively taking Dr. S.A. out of the practice of dentistry to let the dust settle while further legal work was undertaken. This was done under the board’s power to safeguard the health, safety, and welfare of the public.

In this unfolding misconduct case, there’s the issue of “who wins in the end and who wins today?” that was decided against Dr. S.A. when the state dental board immediately suspended the license. The grounds for the action involved several patients for whom Dr. S.A. performed substandard dental work that failed the patient and had to be remedied by other dentists. That answered, “what happens today?”

After extensive, further investigation involving dozens of patient records and procedures performed and billed by Dr. S.A., the board of dentistry issued its ultimate charges against Dr. S.A. alleging over fifty counts of misconduct involving over a dozen patients and multiple procedures where substandard care was performed, documentation was lacking, and dental work was fraudulently billed that was never performed. That answered, “what happens in the end?” where the dentist was put out of practice until further notice.

After a lengthy, active suspension from dentistry and extensive remediation work involving hundreds of hours of extra, supervised, structured training, Dr. S.A. gained back the dental license with participation in the board’s well-being program for dentists impaired because of alcohol, drug abuse, or mental illness. But the true end for Dr. S.A. was still to come. Having overcome these failings, Dr. S.A. fell out of the well-being program resulting in the active suspension of the dentist license to this day.

While extensive cases of fraud can also involve record-keeping and standard of care, some cases involving all of the above have other issues as their root cause – chemical or alcohol dependency and even mental illness that are matters of life or death for the dentist.

Dental practitioners need to know how fraudulent billing can involve record-keeping and substandard care sometimes revealing other, serious issues of impairment. Recovering fraudulent monies and remediating the dentist also can still fail when impairment is now at issue. That is a topic for another day.

About the Author

Mark R. Brengelman, JD, MA, practices health care law in Frankfort, Kentucky, where he is the immediate past Chair of the Health Law Section of the Kentucky Bar Association. For fifteen years, he was the Assistant Attorney General assigned as General Counsel and Prosecuting Attorney to the Kentucky Board of Dentistry. His e-mail is Mark@MarkRBrengelmanPLLC.attorney.