One patient, Antavia Digsby, underwent 14 pulpotomies and received 14 stainless steel crowns in a single sitting on May 9, 2003, when she was 5 years old.
Earlier this month, the Medicaid Dental Center (MDC) agreed to pay $10 million to the U.S. government and the state of North Carolina to settle claims that it fraudulently billed Medicaid for dental care performed on impoverished children at its clinics.
Digsby's attorney, Darren Dawson, has filed the suit on her behalf and said that he will soon be filing suits for 12 more patients with similar complaints, including one who had 16 pulpotomies in a single sitting. He said that all the children were between the ages of 4 and 6 years old.
"The children were very young, the work was done without the full consent of the parent, and some were restrained with a papoose board," Dawson said. "It was unauthorized work to overbill Medicaid."
James Wyatt, MDC's attorney, called the allegations "silly" and added that all parents have to give written consent for any procedures at the clinics. "The children not only needed that work, it was imperative. The real question is why did the parents let their children's teeth get in such a horrible condition?"
The dentists named in the lawsuit are MDC owners Michael A. DeRose, D.D.S., and Letitia L. Ballance D.D.S., and Heather Berkheimer, D.M.D., the dentist who performed the procedures. MDC is now operating under the name Smile Starters.
The $10 million settlement was reached after the government alleged that the chain of clinics run by Dr. DeRose and Dr. Ballance submitted reimbursement claims for unnecessary pulpotomies and stainless steel crowns to Medicaid, and failed to obtain informed consent.
But Wyatt denies that the dentists committed fraud. "All of the work was high-quality," Wyatt said. "The disputed billings involved differences of opinion among knowledgeable experts. All procedures were supported by either X-rays or physical examination."
The charges are regarding procedures done from 2001 to 2003 at the chain's clinics in Charlotte, Raleigh, and Winston-Salem. On October 1, 2004, after the government lawsuit was filed, the North Carolina Medicaid program established a reimbursement limit of six stainless steel crowns per appointment.
This limitation does not apply to hospital operating rooms and ambulatory surgical centers.
"There was a concern that child recipients were in the chair too long, and their welfare was the main motivation behind this change," said Mark Casey, dental director for North Carolina Medicaid.
Nine dentists working for Medicaid Dental Center -- John Lyons, Jeffrey Zieziula, Erron Brady, Lori Petree, Christopher Ballinger, Michelle Wilkerson, Nermin Ballinger, Dr. Balance, and Dr. DeRose -- received written reprimands from the North Carolina Board of Dental Examiners in 2005. Dr. Ballance and Dr. DeRose were placed on probation for three years.
"Health care professionals who abuse their positions and engage in excessive treatment regimens and excessive billing practices will not be tolerated," said Gretchen C.F. Shappert, U.S. Attorney for the Western District of North Carolina, in a written statement.
M. Alec Parker, D.M.D, executive director of the North Carolina Dental Society, argues that the issue is not quite black and white.
Medicaid reimbursement rates to dentists are very low, he noted. If dentists treating Medicaid patients want to stay profitable, it pushes them into a different model of service -- one that requires them to do more procedures, he said.
"I worry about painting these Medicaid centers with a broad brush, because that will put a lot of people who are allowing more access to care out of business," Dr. Parker said.
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