teeth whitening lamp are clamping down on funding for orthodontic and dental services amid a widening investigation into allegations that doctors have routinely sought reimbursement for procedures that aren't covered by Medicaid, including putting braces on youngsters for purely cosmetic reasons and performing unnecessary root canals on small children.
Medicaid, a federal-state program that insures lower-income people, teeth whitening lightonly severe orthodontic conditions, such as children born with a cleft palate or those with dental problems resulting from Down syndrome or muscular dystrophy. The program also covers periodic dental checkups and, when necessary, fillings, crowns and root canals.
While dentists and orthodontists in other states have been accused of Medicaid fraud, the problem appears to be particularly acute in Texas, partly because the state settled a civil lawsuit in 2007 that required it to increase Medicaid funding for dental services, state officials say.
dental scalers, a federal class action filed by parents in 1993 against state officials, alleged Texas was failing in its duty to ensure that children on Medicaid received proper preventative care in dental and other areas. Eligibility for Children's Medicaid in Texas is pegged to income.
In 2007, Texas legislators agreed to settle, conceding that there was a dwindling number of doctors and dentists in the state willing to treat Medicaid patients and agreeing to increase Medicaid-reimbursement rates.
A 2012 report by the House Committee on Oversight and Government Reform offered case studies in various states of supposed Medicaid abuse; it cited dental services in Texas as a particular problem area. By 2010, according to the report, Texas' Medicaid program was spending more on braces than the other 49 state Medicaid programs spent combined on such orthotics.
Last year, the Texas Medicaid program paid out $1.4 billion to dentists and orthodontists—a roughly fourfold increase since 2006, according to state records. The federal government reimburses Texas for 60% of its spending on dental and orthodontic procedures. About 3.3 million of 26.4 million Texans are currently enrolled in Medicaid, according to the Texas Health and Human Services Commission.
Increased Medicaid funding as a result of the settlement has "created a window for fraud," said Stephanie Goodman, a spokeswoman for the Texas HHS.
But as the state has begun aggressively targeting the alleged fraud, some Texas orthodontists say the poor have become unintended victims. Some practices have stopped taking Medicaid patients, while others have shut down amid scrutiny by state investigators.
Erika Mendoza of El Paso visited a clinic in June that had fitted her 13-year-old son with braces the previous year, only to learn it no longer would treat Medicaid patients because the state had frozen its Medicaid funding. She said the clinic offered to remove her son's braces, but she would like him to keep them on until next year.
"I panicked and called every orthodontist in El Paso I could find," said Ms. Mendoza, 31, a single mother who works for a local school district. "Only one doctor would take him—in September."
Kathryn Marquis, who lives in a suburb of Dallas, is still on the hunt for an orthodontist for her two sons, ages 14 and 11, who were dropped in June by their orthodontist but are still outfitted with braces.
"I'm freaked out, because I want the boys to continue with their treatment," said Ms. Marquis, 50. "My youngest son in is pain—one of the braces is cutting into his cheek. The braces haven't been adjusted since June."
The company that treated her sons, All Smiles Dental Professionals P.C., has closed 13 orthodontic offices in the Dallas area in the wake of a state investigation of its practices. The offices served more than 12,000 patients, most of them Medicaid-eligible, according to the firm. The Texas attorney general sued various All Smiles entities in June, alleging it billed Medicaid for services that weren't medically necessary—as well as for services that weren't even performed.
Michael Lozich, All Smiles' chief compliance officer, declined to discuss the litigation but said it relates to procedures that have been abandoned. He said the company is cooperating with federal and state authorities and that it would try to help its former orthodontic patients, including Ms. Marquis's sons, in finding alternative doctors.
William Steinhauer, a San Antonio dentist who heads a Texas Dental Association committee that specializes in Medicaid issues, said he is happy the state is cracking down on fraud. "For too long Texas doctors have been trying to profit off of poor patients," he said.
The Texas Health and Human Services Commission has temporarily denied $8.2 million in Medicaid payments requested by 26 dentists and orthodontists across the state, concluding there is credible evidence the doctors fraudulently overbilled the state.
The Texas attorney general's office has convened a task force to oversee the continuing investigation.
The state also said it is taking steps to help those who have lost care.
"We're trying to get the word out about this resource," said Ms. Goodman of the Texas HHS.
Christine Ellis, a Dallas orthodontist retained last year by the state to audit the Medicaid program, said more than 90% of the 600 reimbursement requests she reviewed were for procedures not covered by Medicaid. "The fraud is statewide and has reached the hundreds of millions of dollars," she said.