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Cases Against Healthcare Fraud by Benevis and Kool Smiles Dental Clinics

Cases Against Healthcare Fraud Benevis and Kool Smiles Dental Clinics

Background of the Cases against Benevis and Kool Smiles Dental Clinics

The U.S. Constitution, through the 1863 False Claims Act (which is also known as the Lincoln Law), forbids any form of extortion or defrauding of government-sponsored programs by federally-contracted persons or companies (Department of Justice, 2011). The case of Benevis and its affiliates (Kool Smiles Dental Clinics) reflects a typical case of a healthcare organization (subcontracted by the state and federal government) knowingly being involved in swindling a federal program (Medicaid) millions of dollars by performing unnecessary procedures on children, as well as submitting false claims of dental procedures performed.

Benevis, LLC (previously called Benevis or NCDR, LLC) is a private firm that offers non-clinical support services to dental clinics and dentists across the U.S., including financial management and administration services. Since 2002, the firm has supported (non-clinical services) Kool Smiles dental clinics spread across the country, including the over 133 Kool Smiles clinics – which operated between 1 January 2009 and 31 December 2011. These clinics are independent entities operated as legal and professional corporations that are owned separately by certified dentists. Throughout their operations, the various Kool Smile Clinics offered dental care services primarily to kids (and, to some extent, adults). This included children (or adults) covered by the Medicaid and TRICARE programs (U.S. Department of Justice, 2018).

Medicaid offers health insurance and coverage to millions of eligible American citizens, especially vulnerable individuals. It supports disabled individuals, elderly adults, pregnant women, children, and low-income adults. Medicaid is a program rendered by states in accordance with federal laws and is conjointly funded by the federal government and states. On the other hand, TRICARE is a health insurance program created to support retirees, uniformed servicemen and women, and their families. This worldwide initiative offers all-inclusive insurance coverage to eligible beneficiaries, including prescriptions, special programs, and health plans.

Charges Filed

The U.S. government, through the Department of Justice, started filing different lawsuits in collaboration with witnesses (dentists and affected families) against Benevis and Kool Smiles dental clinics in 2011 for consciously defrauding the federal and state governments of millions of dollars by performing unnecessary dental procedures on children, as well as writing false billing claims to illegitimately receive Medicaid and TRICARE compensation (Otto, 2018). One example of these cases is documented as the “United States et al., ex rel. Abendano v. NCDR, LLC, et al., 3:10-cv-1100 (JBA) (D. Conn.).”

The plaintiff (The U.S. government) accused Benevis and its partners (Kool Smiles Clinics) of fraud and malpractice between 1 January 2009 and 31 December 2011. Firstly, the petitioner claimed that Benevis and Kool Smiles Clinics knowingly handed in forged claims to TRICARE and Medicaid for placement of “stainless steel crowns” (STCs) on children (pediatric patients) in instances patients did not necessarily require these performed extra-coronal restoration elements. Stainless steel crowns are medically used to restore severely broken teeth and large multi-surface cavities. Some of these claims included but were not limited to STCs inserted on teeth that patients reported no pain or STCs inserted on deciduous teeth (or milk teeth) that were likely to exfoliate naturally without any medical intervention (Whistleblower Attorneys, 2016).

The U.S. government also accused Benevis and its affiliate clinics of forcing their dentists to use the expensive STC procedures while cheaper options were not only available but clinically relevant. The complainant also accused the two organizations of failing to implement adequate and appropriate audit processes that could have averted overutilization. Benevis and Kool Smiles clinics were accused of executing other unnecessary procedures: corona remnant extractions, tooth extractions, and pulpotomies (commonly referred to as baby root canals). The U.S. government also claimed Benevis and Kool Smiles were involved in practices that caused the overutilization of medical procedures carried out on pediatric patients – which endangered the lives of pediatric patients and resulted in the overexploitation of healthcare funds and resources. For example, the plaintiff argued that the dentists employed by the two firms were awarded productivity bonuses on the basis of the revenues made through procedures conducted. Benevis and Smiles’ clinics also participated in scheduling to optimize patient visits, which translated to more revenue and profits for the firms (Burger, 2018).

Punishment, Final Outcome, and Justification

In the final settlement, the jury ruled that the accused (Benevis and Kool Smiles Clinics) must reimburse the U.S. government and other states (that participate in the Medicaid program) a sum of approximately $23,900,000 (U.S. Department of Justice, 2018). This was in addition to the interest accumulated at a rate of about 2 percent per year, starting from 17 November 2016 to the day the last payment was submitted. From this amount, the federal government is to receive $14,244,079.49 (in addition to the accrued interest), while the different Medicaid-participating states are entitled to $9,655,926.51 (in addition to the accumulated interest).

Upon receipt of the money, the U.S. government was required to electronically wire a sum of $1,908,705.85 and $512,786.65 to Relator Abendano and Relators Fitzgerald and Rai, respectively. The three individuals were the whistleblowers that exposed the malpractices at Benevis and Kool Smiles Clinics. They were also the primary witnesses during court proceedings (Whistleblower Attorneys, 2016). This punishment is justified because the accused breached the False Claims Act that bars subcontracted persons or entities from swindling state-funded institutions. It was also unprofessional and unethical for the two firms to endanger pediatric patients’ lives by performing unnecessary procedures. It sounds ludicrous that the two companies were willing to maximize profits at the expense of the health and welfare of innocent and unsuspecting children and their family members.

References

Department of Justice. (2011). The False Claims Act: A primer. Retrieved from https://www.justice.gov/sites/default/files/civil/legacy/2011/04/22/C-FRAUDS_FCA_Primer.pdf

Otto, M. (2018). Dental chain in spotlight after child’s death, separate settlement in fraudulent billing case. Association of Health Care Journalists, https://healthjournalism.org/blog/2018/01/dental-chain-in-spotlight-after-childs-death-separate-settlement-in-fraudulent-billing-case/

U.S. Department of Justice. (2018). Dental management company Benevis and its affiliated Kool Smiles Dental Clinics to pay $23.9 million to settle False Claims Act allegations relating to medically unnecessary pediatric dental services. Justice News, https://www.justice.gov/opa/pr/dental-management-company-benevis-and-its-affiliated-kool-smiles-dental-clinics-pay-239

Whistleblower Attorneys. (2016). Healthcare fraud – Billing for services not rendered. [Video file]. Retrieved from https://www.youtube.com/watch?v=1ZB2fueXn9g

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Question 


Cases Against Healthcare Fraud Benevis and Kool Smiles Dental Clinics

Case: Criminal Law

Please view the following video:

Whistleblower Attorneys. (2016, January 7). Healthcare fraud – Billing for services not rendered. [Video file]. Retrieved from https://www.youtube.com/watch?v=1ZB2fueXn9g

Benevis and Kool Smiles Dental Clinics have joined the ranks of medical professionals and businesses found guilty of defrauding the government. Using the background reading as well as other sources, research the case against this company. After completing your research, please respond to the following questions.

Cases Against Healthcare Fraud Benevis and Kool Smiles Dental Clinics

Cases Against Healthcare Fraud Benevis and Kool Smiles Dental Clinics

  1. Discuss the case against Benevis and Kool Smiles Dental Clinics. Be sure to explain the relationship between the two.
  2. What were the actual charges filed against them?
  3. What was the punishment?
  4. Discuss the final outcome of the case. Was it justified? Be sure to cite reliable sources to support your analysis.

Length: Submit a 3-page paper.

SLP Assignment Expectations

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