Evaluation Essay on Benevis and Kool Smiles Dental Clinics

Introduction

In 2011, the Department of Justice launched an investigation against the dental management company Benevis and 130 of its affiliated Kool Smiles Dental clinics for false claims allegations. The Dental company was facing accusations of billing the Medicaid Programs for dental procedures that were not necessary and some that were never performed. The investigation included Kool Smiles clinics across 17 states. The Benevis case is an example of healthcare frauds that contribute to the soaring healthcare bill in the country. According to Whistleblower Attorneys (2016), the billing for services not rendered is the most common health care fraud. The case of Benevis qualifies as health care fraud because they were exploiting the government and their patients for financial gain. The company itself denied the charges. They termed the allegations as professional disagreements between qualified doctors on what is necessary and what is not.

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Former employees of Benevis clinics filed five lawsuits on behalf of the government under the whistleblower provision of Falls Claims Act(FCA). The False Claims Act allows private citizens as well as the government to file lawsuits against organizations and individuals who are making false claims against the government. For the actions to qualify as false claims, the accused should knowingly submit the false claims. Therefore, clerical mistakes do not count as a violation. One of the whistleblowers was Hartford Courant who told the authorities that appalling practices motivated his decision to blow the whistle. Practices that include wrapping pediatric patients to keep them still and keeping a hair drier in case the patients wet themselves while undergoing a dental procedure. The plaintiff also told the court that the management asks their dentists to include as many procedures as possible into a single appointment when dealing with low-income families, because they are less likely to return.

According to the Department of Justice (2018), the five lawsuits alleged that Kool Smiles clinics submitted false claims for medically unnecessary procedures that include pulpotomies or baby root canals; tooth extractions and crowns. The second lawsuit alleged that some of the claims filed to state Medicaid Programs included pulpotomies that were never performed by the dentists. The third lawsuit alleged that the management pressured the dentists of the organization to meet production goals using cash bonuses that distinguished between productive and unproductive dentists. The reward system depended on the procedures they performed. The fourth lawsuit alleged that Kool Smiles clinics ignored reports of overutilization from some of their dentists. The last lawsuit was against Kool Smiles Clinics in Texas which knowingly presented false claims to the Medicaid Program for the First Dental Home (FDH) which were never fully performed. The FDH are comprehensive packages for children under the age of 3 years that aim to improve the oral health of kids.

Under the FCA, individuals that knowingly submit a false claim to the government are liable to a civil penalty of between $ 5000 and $ 10,000 for each claim they knowingly submitted (FindLaw, 2018). However, the Act allows for adjustments on the penalty which causes violators to pay between $ 10,000 and $ 21,000 per claim. Moreover, the Act allows the government to collect three times the amount of money it has lost due to the false claims. Other than the civil penalties, the perpetrators of false claims may face prison time if their activities violated criminal laws. An example is when those involved in false claims took part in theft, forgery, insurance fraud, identity theft, money laundering, and bribery. The Department of Justice, (2018), says that Dental Care Management Company Benevis and its affiliated Kool Smiles Dental Clinics agreed to pay $23.9 million to the United States plus interest to settle the allegations of false claims. The Federal government is to receive $14,244, 073.49, plus interest from the amount paid by Benevis. An amount of $9,655, 926.51 plus interest, is given to the States that had jointly paid for the false claims submitted to Medicaid Programs. As part of the whistleblower provision provided under the false claims act, three of the former employees who are the whistleblowers will receive a joint amount of $ 2.4 million from the federal share obtained from the settlement.

Despite there being a possibility of insurance fraud and document forgery, no one was convicted or even investigated for these criminal acts. The settlement is an indication of guilt but Benevis still denies any wrongdoing even after agreeing to settle outside of court. The outcome of the case is not justified because the company made significant profits between January 2009 and December 2011. Some of the profits came from false claims. The case should have ended with at least one conviction because the company was taking advantage of children in need; especially the children from poor backgrounds. The settlement is unlikely to make up for the damage the government incurred due to the false claims. The outcome of the case does not do much to deter others from participating in healthcare fraud..

References

Department of Justice. (2018, January 10). Dental Management Company Benevis and Its Affiliated Kool Smiles Dental Clinics to Pay $23.9 Million to Settle False Claims Act Allegations Relating to Medically Unnecessary Pediatric Dental Services. Retrieved from The United States Department of Justice: https://www.justice.gov/opa/pr/dental-management-company-benevis-and-its-affiliated-kool-smiles-dental-clinics-pay-239

FindLaw. (2018). False Claims Act Penalties. Retrieved from FindLaw: https://employment.findlaw.com/whistleblowers/false-claims-act-penalties.html

Whistleblower Attorneys (Director). (2016). Healthcare Fraud - Billing for Services not Rendered [Motion Picture]. United States: Youtube. Retrieved October 16, 2018, from https://www.youtube.com/watch?v=1ZB2fueXn9g