Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

QUESTIONABLE BILLING 

FOR MEDICAID PEDIATRIC 

DENTAL SERVICES 

IN CALIFORNIA 

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 children’s access to Medicaid dental 

care. 

HOW WE DID THIS STUDY 

We analyzed paid fee-for-service claims from California’s 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 providers—representing 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 

pulpotomies—often referred to as “baby root canals”—and 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 
 

 

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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 Medicaid’s 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.” 

California’s 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 child’s teeth are so far out of position that he 

or she cannot engage in normal activities—such 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 Medicaid—2012, 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. 

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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 CSHM’s 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. Attorney’s 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. 

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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 “edits”—system 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 provider’s 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. 

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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 children’s 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. 

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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 

providers”—the providers who provided the services, as opposed to billing 

providers—to 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.dentical.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. 

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measures based on input from officials from CMS, the American Academy 

of Pediatric Dentistry, and the American Dental Association. We also 

discussed these measures—as well as the State’s oversight of Medicaid 

pediatric dental claims—with 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. 

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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 treatment”—generally, 

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 orthodontist—the 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 provider’s 

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. 

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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. 

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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 

Measure 

Average for General 

Dentists * 

Threshold of 

Questionable 

Billing 

Number of Dentists 

Who Exceeded 

Threshold 

Average Number of 

Services Per Day 24 76 229 

Average Payments Per 

Child $166 $412 19 

Average Number of 

Services Per Child Per 

Visit 

5 12 1 

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. 

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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 

Measure 

Average for General 

Dentists * 

Threshold of 

Questionable 

Billing 

Number of Dentists 

Who Exceeded 

Threshold 

Proportion of children 

who received stainless 

steel crowns 

5% 18% 108 

Proportion of children 

who received pulpotomies 5% 18% 98 

Proportion of children 

who received extractions 12% 44% 11 

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 State’s claims 

payment processes for orthodontic services. 

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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/fi941_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 parent’s 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 family’s 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 

board”36 during treatment and failing to monitor the child’s 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 patient’s 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 providers—representing 8 percent of the California general dentists 

and orthodontists we reviewed—received 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 State’s 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 recommendation—that it increase its monitoring 

efforts of dental providers to identify patterns of questionable billing—and 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 recommendation—that it closely monitor 

providers in dental chains for questionable billing—and 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 recommendation—that it review the payment 

processes for orthodontic services—and 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 recommendation—that it take appropriate action 

against the dental providers whom OIG identified as having questionable 

billing—and 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 DHCS’s efforts to protect the program integrity of pediatric dental 

services in California. The full text of the Department’s 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 OIG’s 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.