Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
 
 
Q B  
UESTIONABLE  ILLING 
 
 
M P
FOR  EDICAID  EDIATRIC 
 
 
D S  
ENTAL  ERVICES 
 
C  
IN  ALIFORNIA 
 
Suzanne Murrin 
Deputy Inspector General for 
Evaluation and Inspections 
 
May 2015 
OEI-02-14-00480   
   
EXECUTIVE SUMMARY:  QUESTIONABLE BILLING FOR MEDICAID PEDIATRIC 
DENTAL SERVICES IN CALIFORNIA 
OEI-02-14-0000480 
 
WHY WE DID THIS STUDY 
Medicaid is the primary source of dental coverage for children in low-income families and 
provides access to dental care for approximately 37 million children.  In recent years, a number 
of dental providers and chains have been prosecuted for providing unnecessary dental procedures 
to children with Medicaid and causing harm in the process.  This report is part of a series that 
identifies dental providers with questionable billing in four States:  New York, Louisiana, 
Indiana, and California.  An additional report will look at childrens access to Medicaid dental 
care. 
 
HOW WE DID THIS STUDY  
We analyzed paid fee-for-service claims from Californias Medicaid program for general dentists 
and orthodontists who served 50 or more children with Medicaid in 2012.  Using several 
measures, we identified dental providers with questionable billing who are extreme outliers when  
compared to their peers in California.    
 
WHAT WE FOUND 
We identified 329 general dentists and 6 orthodontists in California with questionable billing.  
Medicaid paid these providers $117.5 million for pediatric dental services in 2012.  These 
335 dental providersrepresenting 8 percent of the California general dentists and orthodontists 
whom we reviewed provided large numbers of services or provided certain services to an 
extremely large number of children, among other practices.  These services included 
pulpotomiesoften referred to as baby root canalsand extractions.  Notably, half of the 
dental providers with questionable billing in California worked for dental chains.  The majority 
of these providers worked for five chains, two of which have been the subject of State and 
Federal investigations. A concentration of providers with questionable billing in chains raises 
concerns that these chains may be encouraging their providers to perform unnecessary 
procedures to increase profits.  
 
Further, our findings raise concerns that certain providers may be billing for services that are not 
medically necessary or were never provided.  They also raise concerns about the quality of care 
provided to children with Medicaid.  Although our findings do not prove that providers either 
billed fraudulently or provided medically unnecessary services, providers with extreme billing 
patterns warrant further scrutiny.  We are engaged in further followup and OIG will take action 
against these providers, as appropriate. 
 
WHAT WE RECOMMEND  
We recommend that the California Department of Health Care Services (1) increase its 
monitoring of dental providers to identify patterns of questionable billing; (2) closely monitor 
billing by providers in dental chains; (3) review its payment processes for orthodontic services; 
and (4) take appropriate action against dental providers with questionable billing.   The 
California Department of Health Care Services concurred with all four of our recommendations. 
   
   
 
TABLE OF CONTENTS 
 
Objective......................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Findings........................................................................................................8 

Three hundred and twenty-nine general dentists and 
six orthodontists in California had questionable billing in 2012  .....8 

Conclusion and Recommendations ............................................................14 

Agency Comments and Office of Inspector General Response .................17 

Acknowledgments......................................................................................23 

   
   
OBJECTIVE 
To identify dental providers with questionable billing for Medicaid 
pediatric dental services in California in 2012. 
BACKGROUND 
Medicaid is the primary source of dental coverage for children in 
low-income families and provides access to dental care for approximately  
37 million children.1  Medicaids Early and Periodic Screening, 
Diagnostic, and Treatment (EPSDT) benefit requires States to cover all 
medically necessary dental services for children 18 years of age and 
under.2  Medicaid dental services must include diagnostic and preventive 
services, as well as needed treatment and followup care.  Diagnostic 
services may include x-rays of the mouth; preventive services may include 
cleanings, topical fluoride applications, and dental sealants.  Dental 
treatment covers a wide range of services such as fillings; tooth 
extractions; and pulpotomies, which are often referred to as baby root 
canals.   
Californias Medicaid program also covers limited orthodontic services.  
The State allows these services only for assessing and treating children 
with handicapping malocclusion, cleft palate, and craniofacial anomalies.3   
Malocclusion occurs when a childs teeth are so far out of position that he 
or she cannot engage in normal activitiessuch as eating and talking 
without difficulty.4  It is commonly associated with other medical 
conditions such as Down syndrome, muscular dystrophy, or craniofacial 
anomalies.  A provider must receive prior approval from the State before 
providing orthodontic treatment to a child.  
In recent years, a number of individual dental providers and chains have 
been prosecuted for providing services that were medically unnecessary or 
____________________________________________________________ 
1 Thomas P. Wall, Dental Medicaid2012, American Dental Association (ADA),  2012. 
See also Centers for Medicare & Medicaid Services (CMS), Annual EPSDT Participation 
Report, Form  CMS-416 (National), Fiscal Year  2012, April 3,  2014. 
2 Social Security Act (SSA)  1905(r)(3);  42  CFR  441.56.  Dental services are covered 
up to age 18, but States may choose to extend eligibility through age 21.  California is 
among the States that have done so. 
3 California Medi-Cal Dental  Program, Medi-Cal  Dental Program Provider Handbook, 
February 2013. 
4 Christine Ellis, University of Texas Southwestern  Medical Center, Division of  Oral and  
Maxillofacial Surgery, Is Government Adequately Protecting Taxpayers from Medicaid 
Fraud?  (written Congressional testimony), April 25, 2012.  Accessed at 
http://oversight.house.gov/wp-content/uploads/2012/04/4-25-12-Ellis-Testimony.pdf on  
October 30, 2013. 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   1   
   
that failed to meet professionally recognized standards of care.  These 
providers have often been found to have Medicaid billing patterns that 
seem suspect in comparison to those of their peers.  For example, in 2013, 
an orthodontist with practices in both Indiana and Texas was convicted for 
health care fraud in Texas and was sentenced to 50 months in prison.5 He 
provided medically unnecessary services and billed for services that were 
never provided. He also maximized Medicaid reimbursement by 
sometimes scheduling more than 100 Medicaid patients per day.         
In addition, FORBA Holdings, LLC (referred to hereafter as FORBA), a 
dental management company that managed clinics nationwide known as 
Small Smiles Centers, settled with the United States in 2010 for 
$24 million to resolve allegations of providing services that were either 
medically unnecessary or performed in a manner that failed to meet 
professionally recognized standards of care to children with Medicaid.6   
As part of the settlement, FORBA agreed to enter into a 5-year Corporate 
Integrity Agreement with the Office of Inspector General (OIG).  FORBA  
subsequently changed its name to Church Street Health Management, 
LLC, and was then acquired by CSHM, LLC. 
In 2012, the Senate Finance and Judiciary Committees investigated CSHM 
and concluded that contrary to CSHMs claims, it was the de facto owner 
of the Small Smiles clinics and that the ownership structure undermined 
the independent, professional, and clinical judgment of Small Smiles 
dentists.7  In April 2014, OIG excluded CSHM from participation in 
Medicaid, Medicare, and all other Federal health care programs for a 
period of 5 years.8 Other dental chains have also been investigated for 
____________________________________________________________ 
5 The U.S. Attorneys Office for the Northern  District of Texas, Amarillo, Texas, 
Orthodontist Sentenced to  50  Months in Federal Prison on  Health Care Fraud 
Conviction, April 9, 2013.  Accessed at http://www.justice.gov/usao/txn/PressRelease/ 
2013/APR2013/apr9goodwin_michael_HCF_sen.html  on  May 8,  2014. 
6 U.S. Department of Justice (DOJ),  National Dental Management Company Pays 
$24 Million  to Resolve Fraud Allegations, January 20, 2010.   Accessed at 
http://www.justice.gov/opa/pr/2010/January/10-civ-052.html on February 20, 2014.  
7 U.S. Senate Committee on Finance and Committee on the Judiciary,  Joint Staff Report 
on the Corporate Practice of  Dentistry in the Medicaid Program, p. 10.  Accessed at 
www.finance.senate.gov/library/prints/download/?id=1c7233e0-9d08-4b83-a530-
b761c57a900b on  February 20, 2014. 

8 The exclusion was effective  September 30, 2014.  OIG,  OIG Excludes Pediatric Dental 
 
Management Chain From Participation in Federal Health  Care Programs. Accessed at 

http://oig.hhs.gov/newsroom/news-releases/2014/cshm.asp on  April 4, 2014. 

Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   2   
   
allegedly encouraging their providers to perform unnecessary procedures 
to increase profits.9   
California Medicaid Dental Claims 
California covers biannual dental screenings for children with Medicaid 
under the age of 21, as well as covering medically necessary treatment 
services.10   The biannual screenings generally consist of an examination, 
x-rays, cleaning, a topical fluoride application, and oral hygiene 
instruction.  Treatment services include fillings, crowns, and oral 
surgery.   The State has a number of specific policy guidelines for when 
certain services are covered, as well as frequency limitations for certain 
services. The State also requires prior approval for some services, such as 
orthodontia. 
California has several systems in place to oversee Medicaid pediatric 
dental claims. The State has claims-processing editssystem processes 
that compare claims data to Medicaid requirements in order to approve or 
deny claims or flag them for further review.  For example, one of these 
edits checks whether services were provided more frequently than the 
State allows. In addition, the State conducts utilization reviews on at least 
a quarterly basis. As part of these reviews, the State has an automated 
data system that monitors utilization of all pediatric dental services and 
specific services.  Through this process, the State uses aberrant utilization 
patterns to identify individual providers for additional scrutiny, which may 
include a review of a providers patient records and may result in further 
investigation.  
Related Work 
OIG is conducting a larger body of work focusing on Medicaid pediatric 
dental services. This report is part of a series that identifies dental 
providers with questionable billing.11   The first report in this series 
____________________________________________________________ 
9 In addition to CSHM, the Senate Finance and Judiciary Committees investigated the 
following chains:  Kool Smiles, ReachOut Healthcare  America, Heartland Dental Care, 
and Aspen  Dental Management.  In addition,  other dental chains have also  been the 
subject of Federal and State investigations.  For example, in 2012, the All Smiles chain  
and its owner agreed to  pay the United States and State of Texas $1.2 million to resolve 
allegations that All Smiles violated the civil False Claims Act and the Texas Medicaid 
Fraud Prevention Act.  DOJ,  Texas Orthodontic Clinic and Former Owner Resolve 
Allegations of False Medicaid  Claims, March 21, 2012.  Accessed at  
http://www.justice.gov/usao/txn/PressRelease/2012/MAR2012/mar21Malouf_AllSmiles_ 
Settlement_PR.html on June  13, 2014. 
 
10 Coverage may continue until the last day of the month in which the child turns 21.  

California Code of Regulations  22 CCR  50193. 

11 The reports in  this series are all based on a similar methodology that analyzed paid
  
fee-for-service claims  for dental providers who served  50 or more children with Medicaid 

during 2012. 

Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   3   
   
identified 23 general dentists and 6 orthodontists with questionable billing 
in New York.12  Medicaid paid these providers $13.2 million for pediatric 
dental services in 2012. Almost a third of these 23 general dentists were 
associated with a single dental chain that had settled lawsuits for providing 
services that were medically unnecessary or that failed to meet 
professionally recognized standards of care to children.  
The second report in this series identified 26 general dentists and  
1 oral surgeon with questionable billing in Louisiana.13 Medicaid paid 
these providers $12.4 million for pediatric dental services in 2012.  Almost 
a third of the providers worked for two dental chains. 
The third report in this series identified 94 general dentists and 1 oral 
surgeon in Indiana with questionable billing. 14 Medicaid paid these 
providers $30.5 million for pediatric dental services in 2012.  Two-thirds 
of the general dentists with questionable billing worked for four dental 
chains.  
Further, a 2013 OIG audit found that providers inappropriately billed for 
orthodontic services provided to 43 of 100 sampled beneficiaries in 
New York City, totaling an estimated $7.8 million in inappropriate 
reimbursement.15  Some of these services were provided without the 
required annual approval, whereas other services were undocumented or 
were never provided. These deficiencies occurred because the State 
agency and providers did not ensure that cases were reviewed annually to 
determine the need for continuing care and did not ensure that services 
were adequately documented.   
An additional report covering multiple States will look at childrens access 
to Medicaid dental care.16  It will describe the extent to which children 
enrolled in Medicaid received dental services in these States.    
 
____________________________________________________________ 
12 OIG,  Questionable Billing for Medicaid Pediatric Dental  Services in New York, 
OEI-02-12-00330, March  2014. 

13 OIG,  Questionable Billing for Medicaid Pediatric Dental  Services in Louisiana, 

OEI-02-14-00120, August 2014. 

14 OIG,  Questionable Billing for Medicaid Pediatric Dental  Services in  Indiana, 
OEI-02-14-00250, November  2014. 

15 OIG,  New York Improperly Claimed Medicaid Reimbursement for Orthodontic 

Services to Beneficiaries in New York City, A-02-11-01003, October 2013. 

16 OIG,  Access to Medicaid  Dental Care for Children, OEI-02-14-00490, forthcoming. 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   4   
   
METHODOLOGY   
We based our analysis on California Medicaid paid fee-for-service dental 
claims for children under 21 with service dates from January 1, 2012, 
through December 31, 2012.  California covers Medicaid dental services 
on a fee-for-service basis  for most of the State.17  We excluded claims for 
services with special payment rates, such as those submitted by Federally  
Qualified Health Centers.18   We analyzed claims from rendering dental 
providersthe providers who provided the services, as opposed to billing 
providersto ensure that we compared claims from the providers who 
performed the services. 
We focused our analysis on general dentists and orthodontists.19   We  
analyzed the two provider types separately because their billing patterns 
varied significantly.   We did not include pediatric dental specialists 
because the wide variation in their billing behavior made it difficult to 
analyze them as one peer group. Some  pediatric dental specialists provide 
services that make them similar to general dentists, while others in this 
group provide more complex services.  In addition, we did not do a 
separate analysis of other dental specialists because there were too few to 
analyze.20  
General Dentists  
Our analysis focused on 3,921 general dentists who provided services to 
50 or more children with Medicaid during 2012.21   We developed a 
number of measures to identify dentists with questionable billing who are 
extreme outliers when compared to their peers.  We developed these 
____________________________________________________________ 
17  In Los Angeles County, Medicaid beneficiaries have the option to  receive dental 
services through managed care, while in  Sacramento County, Medicaid dental services 
are provided only through managed care.  California Department of Health Care Services, 
Overview: Medi-Cal  Dental  Managed Care.  Accessed at http://www.denti-
cal.ca.gov/WSI/ManagedCare.jsp?fname=ManagedCareOverview on November 10, 
2014. 
18  We also excluded services provided in a  hospital setting because these services differ 
from services provided in an office setting.  In total, we identified  8,627 dental providers 
who  provided  services to any children with Medicaid in 2012 on a fee-for-service basis.   
19  We also analyzed 89 oral surgeons who provided services to 50  or more children  with  
Medicaid  and identified 6 with questionable billing.  However, after reviewing their 
backgrounds, as well as their claims and payment histories, we determined that their 
billing  was more similar to that of general dentists than to that of other oral surgeons. For 
example, these providers performed a significantly higher proportion  of diagnostic and 
preventive services than other  oral surgeons, who typically  performed a more complex 
set of procedures. Thus, we did not include them in our analysis. 
20  In 2012, 3 periodontists, 3  prosthodontists, 2 endodontists,  and 1 oral pathologist  
provided services to  50  or more children with Medicaid in  California.   

21 California had more general  dentists than  any of the other  three States that we 

reviewed.  In comparison, we analyzed 719 dentists in  New York who served  50 or more 

children, 512 in Louisiana, and 787 in  Indiana. 

Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   5   
   
measures based on input from officials from CMS, the American Academy 
of Pediatric Dentistry, and the American Dental Association.   We also 
discussed these measuresas well as the States oversight of Medicaid 
pediatric dental claimswith staff from the State Medicaid agency, the 
California Department of Health Care Services.  We developed these 
measures to identify several different types of possible fraud, waste, and 
abuse. For these measures, we included only the children with Medicaid 
served by these dental providers; we did not include other children whom  
they served.  
For each general dentist, we calculated the following three measures for 
2012: 
   the average Medicaid payment per child served,  
   the average number of services provided per day, and 
   the average number of services provided per child per visit. 
We developed four additional measures for general dentists who provided 
selected services in 2012.  For each dentist who provided the following 
service, we calculated the proportion of children with Medicaid who 
received: 
  fillings,  
  extractions,  
  stainless steel crowns, and 
  pulpotomies.  
For each measure, we analyzed the averages and the distribution for all 
general dentists. 
Next, we set a threshold for each measure that, if exceeded, indicated that 
the dentist had billed an extremely high amount or number compared to 
other general dentists in the State.  We used a standard technique for 
identifying outliers, known as the Tukey method.22  Under the Tukey 
method, outliers are values greater than the 75th percentile plus 1.5 times 
the interquartile range. Additionally, under this method, extreme outliers 
are values greater than the 75th percentile plus 3 times the interquartile 
range. For this study, we employed only this more conservative approach 
to identify extreme outliers.  We considered dentists who exceeded the 
threshold for one or more of the seven measures to have questionable 
billing. 
 
____________________________________________________________ 
22 See J.W. Tukey, Exploratory Data  Analysis.  Addison-Wesley, 1977.  
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   6   
   
Orthodontists  
We did a separate analysis of orthodontists.  We analyzed  
170 orthodontists who provided orthodontic services to 50 or more 
children with Medicaid in 2012. These orthodontists served a total of 
63,728 children with Medicaid. In California, providers receive a 
one-time payment for comprehensive orthodontic treatmentgenerally, 
this is the initial placement of braces on the teeth.   They may also bill 
quarterly for periodic treatment visits, which cover the ongoing 
maintenance of the orthodontia.  The remaining few orthodontic services 
may be billed for as they are provided.   
Because of the way that orthodontists are paid, we calculated one measure 
for each orthodontistthe total number of children who received 
orthodontic services.23   As with our analysis for general dentists, for this 
measure, we set the threshold for extreme outliers at the 75th percentile 
plus 3 times the interquartile range.  Orthodontists who exceeded this 
threshold were extreme outliers compared to their peers, and we 
considered them to have questionable billing. 
Additional Analysis 
For each dental provider who exceeded the threshold for one or more of 
the measures, we conducted Internet searches on the providers  
background and analyzed his or her claims and payment history. In some 
cases, we excluded providers who were actually specialists but had not 
indicated this on their claims.  For the remaining providers, we identified 
providers who worked for a dental chain in 2012, based on the billing 
addresses associated with their claims.24   We researched public records to 
determine whether any of these providers or chains had been the subject of 
State or Federal investigations.   
Limitations 
We designed this study to identify dental providers who warrant further 
scrutiny.  None of the measures that we analyzed confirm that a particular 
provider is engaging in fraudulent or abusive practices.  Some providers 
may be billing extremely large amounts or numbers for legitimate reasons.   
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency. 
____________________________________________________________ 
23 To compare their billing for orthodontic services, we analyzed  only claims  for 
orthodontic services performed by these providers. 
 
24  We  defined a dental chain as an entity with  five  or more locations  within a State or 

around the country. 

Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   7   
   
FINDINGS 
Three hundred and twenty-nine general dentists and 
six orthodontists in California had questionable billing 
in 2012 
We identified 329 general dentists and 6 orthodontists with questionable 
billing.  We identified these providers by looking at general dentists and 
orthodontists in California who served more than 50 children with 
Medicaid in 2012. 
The providers with questionable billing are extreme outliers when 
compared to their peers.  Although they made up only 8 percent of the 
general dentists and orthodontists that we reviewed, they provided care to 
34 percent of the children with Medicaid served by the general dentists 
and orthodontists we reviewed.25  Medicaid paid these 335 providers 
$117.5 million for pediatric dental services in 2012.  Notably, we found 
that almost a third (101) of the general dentists exceeded the threshold for 
more than one questionable billing measure, with 34 dentists exceeding 
3 or more measures. 
Half of the dental providers with questionable billing worked for dental 
chains. The majority of these providers worked for five chains, two of 
which have been the subject of State and Federal investigations. 
These patterns raise concerns that certain dental providers may be billing 
for services that are not medically necessary or were never provided.  
They also raise concerns about quality of care.  Although our findings do 
not prove that providers either billed fraudulently or provided medically 
unnecessary services, providers who bill for extremely large numbers of  
services warrant further scrutiny.  
Two hundred and twenty-nine general dentists provided an 
extremely large number of services per day 
General dentists in California provided an average of 24 services per day 
to children with Medicaid; however,  229 dentists each averaged at least  
76 services per day.   Two dentists averaged more than 500 services per 
day, with one of them averaging 862 services per day.   These two dentists 
provided extremely large numbers of services on certain days of the year.  
One of them provided more than 1,000 services per day on 97 different 
days. On one day, he provided 1,658 services.  If this dentist spent only  
5 minutes performing each service, it would have taken over 138 hours to  
____________________________________________________________ 
25 The 3,921  general dentists and 170 orthodontists whom we reviewed served a total of  
1.4 million children with Medicaid.  Some children were seen by both a general  dentist  
and an orthodontist.   
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   8   
   
complete all of these services.  An extraordinarily large number of services 
per day raises concerns that a dentist may be billing for services that were 
not medically necessary or were never provided, as well as raising 
concerns about the quality of care being provided.  See Table 1 for more 
information on general dentists with extremely large numbers of services 
or high average payments.   
Table 1: General Dentists With Extremely High Average Payments or Large 
Numbers of Services 
Threshold of  Number of Dentists 
Average for General  Questionable   Who Exceeded 
Measure   Dentists *   Billing  Threshold  
Average Number of 
24  76  229 
Services Per Day   
Average Payments Per 
$166  $412   19 
Child 
Average Number of 
Services Per Child Per  5  12  1 
Visit  
Source:  OIG analysis of California Medicaid claims data, 2014.   
                        
Note: Two dentists each exceeded two thresholds. 

* Includes general  dentists who served 50 or more  children with Medicaid in 2012.  
 
 
Nineteen general dentists received extremely high payments 
per child 
General dentists in California received an average payment of $166 for 
each child with Medicaid.  Nineteen dentists, however, received an 
average of more than $412 per child. One dentist averaged $699 per child. 
Five of these dentists received more than $3,000 per child for a total of 
10 children. Extremely high payments raise concerns about whether these 
dentists are billing for unnecessary services or for services that they did 
not provide.  
One general dentist provided an extremely large number of 
services per child per visit 
General dentists in California provided an average of five services per 
Medicaid child during a single visit.  One dentist, however, averaged more 
than 12 services per child per visit.  This dentist provided extremely large 
numbers of services to certain children during a single visit, raising 
concerns both about potential fraudulent billing and about quality of care.   
She provided more than 20 services in a single visit to a total of   
30 children. For example, she provided 33 services to a 4-year-old child 
during a single visit. These services included 13 stainless steel crowns 
and 11 pulpotomies.   
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   9   
   
One hundred and twenty-nine general dentists provided 
selected services to an extremely high proportion of children 
they served 
When compared to their peers in the State, 129 general dentists provided 
selected services to an extremely high proportion of children with 
Medicaid that they served.  This billing behavior warrants further scrutiny, 
as it may indicate billing for services that were not medically necessary or 
were never provided. It also raises concerns about quality of care and 
whether children treated by these dentists were harmed by these 
procedures. See Table 2 for more information on general dentists who 
provided selected services to an extremely high proportion of children. 26  
Table 2: General Dentists Who Provided Selected Services to an Extremely  
High Proportion of Children With Medicaid They  Served  
Threshold of  Number of Dentists 
Average for General  Questionable   Who Exceeded 
Measure   Dentists *   Billing  Threshold  
Proportion of children 
who received stainless  5%  18%   108 
steel crowns  
Proportion of children 
5%  18%   98 
who received pulpotomies 
Proportion of children 
12%  44%   11 
who received extractions 
 
Source:  OIG analysis of California Medicaid claims data, 2014. 

Note: Eighty-eight dentists each exceeded two thresholds. 

* Includes general  dentists who served 50 or more  children with Medicaid in 2012.  
 
Stainless Steel Crowns. One hundred and eight general dentists provided 
stainless steel crowns to an extremely high proportion of children with 
Medicaid that they served. Eighteen percent or more of the children 
served by these dentists received stainless steel crowns, compared to an 
average of only 5 percent of children served by all general dentists who 
provided stainless steel crowns.  Additionally, nine of these dentists 
provided more than 15 stainless steel crowns per visit to 10 children, 
ranging from 2 to 5 years old. 
Pulpotomies. Ninety-eight general dentists provided pulpotomies to an 
extremely high proportion of children with Medicaid that they served.  
Eighteen percent or more of the children served by these dentists received 
pulpotomies, compared to a Statewide average of only 5 percent.  Six of 
these dentists provided pulpotomies to more than half of the children they 
____________________________________________________________ 
26 No dentists exceeded the threshold for the proportion of Medicaid children receiving 
fillings.  General dentists provided fillings  to  an average of 34  percent of children served; 
however, none of the dentists exceeded  the threshold of 99 percent. 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   10   
   
served, with one dentist providing pulpotomies on 68 percent of the 
children he served. 
Further, 9 dentists provided at least 15 pulpotomies per child per visit to a 
total of 15 children, with ages ranging from 3 to 5 years old.  In one case, 
a dentist provided 19 pulpotomies and 15 other services to a 3-year-old 
child. In another case, a dentist provided 19 pulpotomies and 21 other 
services to a 5-year-old child.  If these services were actually provided, it 
raises concerns about quality of care and whether these children were 
harmed. 
Extractions. Eleven general dentists performed tooth extractions on an 
extremely high proportion of the children with Medicaid that they served.   
Forty-four percent or more of the children served by these dentists had one 
or more teeth extracted, compared to an average of 12 percent of children  
served by general dentists performing extractions on children with 
Medicaid in the State. Seven of these eleven dentists performed 
extractions on more than 80 percent of the children they served, with one 
dentist performing extractions on 98 percent of the children he served.   
Six orthodontists provided services to an extremely large  
number of children 
Orthodontists in California provided orthodontic services to an average of  
169 children with Medicaid in 2012.  Six orthodontists, however, each 
provided services to 584 or more children.  One of these orthodontists 
provided services to 1,079 children.   
All six of these orthodontists most often provided periodic treatment 
services, which accounted for more than three quarters of the orthodontic 
services that they provided in 2012.  These 6 orthodontists billed for a 
total of 7,878 periodic treatment services for 3,439 children over the 
course of the year.  Further, two of the orthodontists worked for one dental 
practice, while two others worked for another dental practice, raising 
concerns that these practices may be encouraging inappropriate billing. 
The high volume of children served by each of these six orthodontists 
raises concern about whether they are able to ensure that each child 
receives treatment that meets professionally recognized quality-of-care 
standards. Moreover, it is possible that the orthodontists billed for 
services that they did not even provide.  Also, as previously noted, 
California covers orthodontic treatment only for children with severe 
dental problems, such as malocclusion or cleft palate, and requires that 
providers seek prior approval before performing these services.  These 
orthodontists billing patterns raise concerns about the States claims  
payment processes for orthodontic services.   
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   11   
   
Half of the dental providers with questionable billing worked 
for dental chains; the majority worked for five dental chains  
Of the 335 dental providers with questionable billing, 166 general dentists 
and 1 orthodontist worked for 13 dental chains in California.27   
Eighty percent (134) of these providers worked for 5 dental chains, 2 of 
which have been the subject of Federal and State investigations.  A  
concentration of dental providers with questionable billing in chains raises 
concerns that these chains may be encouraging their providers to perform  
unnecessary procedures to increase profits. 
One of the five chains employed 44 general dentists and 1 orthodontist 
with questionable billing. It was the subject of an investigation by DOJ 
and the U.S. Postal Service for alleged insurance fraud.28   This 
investigation stemmed from allegations by former employees of the chain 
that they had often submitted claims to insurers that were double the actual 
amount charged to patients.  Additionally, in the late 1990s, California 
State regulators investigated the chain for Medicaid fraud.29   The chain 
settled with the State for $1.7 million and agreed to allow outside 
monitoring of its business activities.30    
A second chain operates mobile school-based clinics around the country.   
Twenty-nine general dentists with questionable billing worked for this 
chain in California. Four dentists with questionable billing that we 
identified in Louisiana and 13 in Indiana also worked for this chain.31 It 
has been the subject of investigations arising from complaints that dentists 
affiliated with it had treated children without their parents permission and 
had provided medically unnecessary services.32 The Senate Finance and 
Judiciary Committees also investigated this chain, citing a potential 
____________________________________________________________ 
27 Notably, 22 of these dentists worked for more than  1 chain in  2012, with  1  provider 
working for 4 chains. 
  
28  David R. Olmos, Federal Agents  Raid Offices of Western Dental, Los Angeles 

Times,  June 7, 1997.  Accessed at  http://articles.latimes.com/1997-06-07/business/fi-
941_1_western-dental  on October 29, 2014. 

29 Ibid. 

30 David R.  Olmos, Western Dental Agrees to Pay $1.7 Million to  Settle Charges, 

Los Angeles Times,  July 1, 1997.  Accessed at http://articles.latimes.com/1997/jul/01/  

business/fi-8526 on  October 29, 2014. 

31 OIG,  Questionable Billing for Medicaid Pediatric Dental  Services in Louisiana, 

OEI-02-14-00120, August 2014, and Questionable Billing  for Medicaid Pediatric Dental  
Services in Indiana, OEI-02-14-00250, November  2014. 

32 Sydney P. Freedberg, Dental Abuse Seen  Driven by  Private Equity Investments, 

Bloomberg News May 16, 2012.  Accessed at http://www.bloomberg.com/news/2012-05-
17/dental-abuse-seen-driven-by-private-equity-investments.html on  April 25, 2014. 

Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   12   
   
pattern of treatment without parental consent.33  For example, according to  
the Committees report, a 4-year-old medically fragile boy in Arizona 
was treated without a parents consent, receiving pulpotomies and stainless 
steel crowns while being physically restrained by three staff 
members.34  Subsequent examinations initiated by the family suggested 
that the dental work provided was unnecessary.  Further, the Dental Board 
of California initiated an investigation against this chain in 2012 in 
response to allegations that one of the dentists that we found to have 
questionable billing had unnecessarily pulled four teeth from a 
third-grader without obtaining the familys consent.35    
The remaining 3 chains employed a total of 69 dentists with questionable 
billing. Additionally, another 8 chains employed 44 dentists with 
questionable billing. The number of dentists with questionable billing 
who worked for each of these 8 chains ranged from 2 to 10. 
Twelve of the general dentists with questionable billing have 
been subject to disciplinary action by the State dental board 
Twelve of the general dentists with questionable billing have been subject 
to disciplinary action by the Dental Board of California.  The Board either 
took action or initiated action against six of these providers for providing 
care that failed to meet quality-of-care standards.  Specifically, the Board 
placed one dentist on probation for 5 years for erroneously sedating, 
overdosing, and failing to adequately monitor a 5-year-old child.  The 
Board placed another dentist on probation for 3 years for restraining 
children without parental consent. The Board also initiated disciplinary 
action against another dentist for restraining a 4-year-old with a papoose 
board36 during treatment and failing to monitor the childs condition 
properly.   Additionally, the Board either took action or initiated action 
against two dentists for committing insurance fraud, billing for services 
that they did not provide, and backdating insurance claims.  Finally, the 
Board took action against three other dentists after they were convicted of 
criminal activity or failed to disclose a prior criminal conviction on their 
application for a license.  
____________________________________________________________ 
33 U.S. Senate Committee on Finance and Committee on the Judiciary,  Joint Staff Report 
on the Corporate Practice of  Dentistry in the Medicaid Program.  Accessed at 
www.finance.senate.gov/library/prints/download/?id=1c7233e0-9d08-4b83-a530-
b761c57a900b on  February 20, 2014. 

34 Ibid. 

35 Sydney P. Freedberg, Dental Abuse Seen  Driven by  Private Equity Investments, 

Bloomberg News, May 16, 2012.  Accessed  at http://www.bloomberg.com/news/2012-
05-17/dental-abuse-seen-driven-by-private-equity-investments.html  on April 25, 2014. 
 
36 A papoose board is a board  with straps that is used to limit a patients movement and 

hold the patient steady during a medical procedure. 
 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   13   
   
CONCLUSION AND RECOMMENDATIONS 
Dental providers who participate in Medicaid provide much-needed access to 
dental services for children in the program.   When children lack such access, 
untreated decay and infection in their mouths can result in more complicated and 
expensive dental and medical interventions later in life.  At the same time, 
however, this report raises concerns about the extreme billing patterns of a 
number of general dentists and orthodontists in California.  Specifically, these 
335 dental providersrepresenting 8 percent of the California general dentists 
and orthodontists we reviewedreceived extremely high payments per child; 
provided an extremely large number of services per day; provided an extremely 
large number of services per child per visit; provided services to an extremely 
large number of children; and/or provided certain selected services to an 
extremely high proportion of children. Medicaid paid these providers 
$117.5 million for pediatric dental services in 2012.  Although our findings do not 
prove that providers either billed fraudulently or provided medically unnecessary 
services, providers with extreme billing patterns warrant further scrutiny.  
Our findings raise concerns that certain dental providers may be billing for 
services that are not medically necessary or were never provided.  They also raise 
concerns about quality of care and whether children treated by these providers 
were harmed by these procedures.  Prior OIG reports have also found 
vulnerabilities in the oversight of Medicaid dental providers.  Additionally, we 
identify specific vulnerabilities regarding the practices of certain dental chains.  
Notably, half of the dental providers in California with questionable billing 
worked for dental chains. The majority of these providers worked for five chains, 
two of which have been the subject of State and Federal investigations.  
A concentration of providers with questionable billing in chains raises concerns 
that these chains may be encouraging  their providers to perform unnecessary 
procedures to increase profits. 
Together, these findings demonstrate the need to improve the oversight of 
Medicaid pediatric dental services.  OIG is engaged in further followup and will 
take action against providers with questionable billing, as appropriate.  We are 
also committed to examining access to Medicaid dental care and to continuing to 
conduct investigations and audits of specific dental providers.   
California must use the tools at its disposal to effectively identify and fight fraud, 
waste, and abuse, while at the same time ensuring that children have adequate 
access to quality dental care in the Medicaid program.   
Therefore, we recommend that the California Department of Health Care 
Services: 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   14   
   
Increase its monitoring of dental providers to identify patterns of 
questionable billing 
The State should increase its monitoring of Medicaid dental providers.  To do this, 
it should use the measures that we developed for this report to better identify 
providers with patterns of questionable billing.  State monitoring can result in cost 
savings, as well as ensuring that children receive quality dental care. 
Closely monitor billing by providers in dental chains  
A concentration of dental providers with questionable billing in a small number of 
dental chains raises concerns that these chains may be encouraging their providers 
to perform unnecessary procedures to increase profits.  We recommend that 
California more closely monitor claims that are submitted by providers in dental 
chains. To do so, the State must (1) identify the chains in California, (2) identify 
all Medicaid providers in each chain, and (3) review claims from providers in 
each chain for patterns of questionable billing.  The State should then follow up 
regarding individual providers and chains as warranted.     
Review its payment processes for orthodontic services  
The high volume of children served by  each of the six orthodontists with 
questionable billing raises concerns about how the State pays for orthodontic 
services. The State should review its payment processes to ensure that all 
orthodontic services provided are consistent with State requirements and paid for 
appropriately. 
Take appropriate action against dental providers with questionable 
billing 
In a separate memorandum, we will refer to the State the dental providers whom  
we identified as having questionable billing.  The State should review these 
providers billing patterns; review dental records and supporting documentation; 
and/or perform unannounced site visits.  Then the State should determine what 
action(s) are most appropriate.  These actions include, but are not limited to 
(1) law enforcement actions, if fraud is identified; (2) referral to the States board 
of dentistry for licensure violations; (3) recoupment of payments, if the State 
determines that claims were paid in error; (4) revocation of Medicaid billing 
privileges; (5) education about how to appropriately bill for pediatric dental 
services; and (6) no action, if the State determines that a given provider does not 
demonstrate a vulnerability to the program or to children with Medicaid.   
 
   
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   15   
   
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL  
RESPONSE 
The California Department of Health Care Services (DHCS) concurred with all 
four of our recommendations. 
DHCS concurred with our first recommendationthat it increase its monitoring 
efforts of dental providers to identify patterns of questionable billingand stated 
that it will ensure this through its fiscal intermediary.  Although DHCS has a 
Surveillance and Utilization Review Subsystem that identified providers with 
questionable billing, the criteria and methodology utilized in the system are not 
identical to the method described in the OIG report.  DHCS said that an analysis 
and comparison of the criteria will be conducted by December 2015 and 
modifications to the existing criteria will be implemented.  
DHCS concurred with our second recommendationthat it closely monitor 
providers in dental chains for questionable billingand said that it would do so 
and take appropriate action within its authority to pursue.  DHCS said that it will 
review the details of each case identified by OIG to determine whether any 
improvements need to be made to its claims processes and will implement 
changes by December 2015.  
DHCS concurred with our third recommendationthat it review the payment 
processes for orthodontic servicesand said that it will review the information 
provided by OIG and examine the extent to which claims processing for 
orthodontia services can be improved.  
DHCS concurred with our fourth recommendationthat it take appropriate action 
against the dental providers whom OIG identified as having questionable 
billingand said that it would do so as permitted within its authority to pursue.  
DCHS said that it will review the dental providers referred by OIG and will 
determine by December 2015 what appropriate action may be warranted. Should 
there exist any provider cases not previously evaluated by existing program 
monitoring efforts, DHCS will take appropriate action through the available 
channels.  
OIG supports DHCSs efforts to protect the program integrity of pediatric dental 
services in California. The full text of  the Departments comments is provided in 
the Appendix. 
 
 
   
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   16   
   
APPENDIX 
Agency Comments 
 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   17  
   
APPENDIX 
Agency Comments (continued) 
 
 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   18   
   
APPENDIX 
Agency Comments (continued) 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   19  
   
APPENDIX 
Agency Comments (continued) 
 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   20  
   
APPENDIX 
Agency Comments (continued) 
 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   21   
   
APPENDIX 
Agency Comments (continued) 
 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   22   
   
ACKNOWLEDGMENTS 
This report was prepared under the direction of Jodi Nudelman, Regional 
Inspector General for Evaluation and Inspections in the New  York regional office, 
and Nancy Harrison and Meridith Seife, Deputy Regional Inspectors General.  
Lucia Fort served as team leader for this study.  Other Office of Evaluation and 
Inspections staff from the New York regional office who conducted the study 
include Judy Kellis.  Central office staff who provided support include 
Clarence Arnold, Meghan Kearns, and Christine Moritz. 
 
Questionable Billing for Medicaid Pediatric Dental Services in California (OEI-02-14-00480)   23   
   
Office of Inspector General
http://oig.hhs.gov  
 
The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as  
amended, is  to protect the integrity of the Department of  Health and Human Services  
(HHS)  programs, as well as the health and welfare of beneficiaries  served by those 
programs.  This statutory mission  is  carried  out through  a nationwide network  of  audits, 
investigations, and inspections conducted by the  following operating components: 
Office of Audit Services 
The Office  of  Audit Services  (OAS) provides auditing services  for HHS, either by  conducting  
audits  with its own audit resources or by  overseeing  audit work done by others.  Audits  
examine the performance of HHS programs and/or its grantees and contractors in carrying  
out their respective responsibilities and are intended  to provide independent assessments of 
HHS programs and operations.  These assessments help reduce waste, abuse, and  
mismanagement and promote economy and efficiency  throughout  HHS. 
Office of Evaluation and Inspections 
The Office  of  Evaluation and Inspections (OEI)  conducts national evaluations to  provide 
HHS, Congress, and the public with timely, useful, and reliable information on significant 
issues.  These evaluations focus on preventing fraud,  waste, or abuse  and promoting  
economy, efficiency, and effectiveness of departmental programs.  To promote impact, OEI 
reports also present practical recommendations for improving program operations.  
Office of Investigations 
The Office of Investigations (OI) conducts criminal, civil, and administrative investigations  
of  fraud and misconduct  related to HHS programs, operations, and beneficiaries.  With 
investigators working in all 50 States and the District of Columbia, OI  utilizes its resources 
by actively  coordinating with the Department  of Justice  and other Federal, State, and local 
law enforcement authorities.  The investigative efforts of OI often lead to  criminal 
convictions, administrative sanctions,  and/or  civil monetary  penalties.  
Office of Counsel to the Inspector General 
The Office of Counsel to the  Inspector  General (OCIG) provides general legal services to 
OIG, rendering  advice and opinions on HHS programs and operations and  providing all  
legal support for OIGs  internal operations.  OCIG represents  OIG in all civil and 
administrative fraud and abuse cases involving HHS programs,  including False Claims Act, 
program exclusion, and civil monetary penalty cases.  In  connection with these cases, OCIG 
also negotiates and monitors corporate integrity agreements.  OCIG renders advisory 
opinions, issues compliance program  guidance, publishes fraud alerts, and provides other  
guidance  to  the health care industry concerning the anti-kickback statute and other  OIG  
enforcement authorities.