Medicaid dental clinics probed
Houston girl’s case shines light on risky practices, critics say
For three months, Courissa Hall essentially lived in a Houston rehabilitation hospital providing care for her 4-year-old daughter, who suffered brain damage during a routine appointment at a local dental clinic that specialized in treating Medicaid patients.
She’s still processing the calamity that left her daughter Nevaeh, healthy and rambunctious before the January appointment, now unable to walk or talk or respond to instructions. The victim of apparent overmedication at the clinic, Nevaeh lies in bed, a feeding tube providing her nutrition, her limbs contracting involuntarily from neurological damage. It’s heartbreaking to watch, her mother said.
On April 8, Hall took the big step of seeking criminal charges at the Harris County District Attorney’s Office against her daughter’s dentist, Dr. Bethaniel Jefferson, alleging reckless endangerment of a child. Separately, state officials will decide this month whether to make permanent the temporary suspension of her dental license.
“Once we found what went on behind closed
doors, we determined she needs to go to jail,” Hall said. “No dentist should be able to get away with what was done to my girl.”
This case has opened a window on Medicaid dental clinics that prosper by treating an abundance of pediatric patients whose low-income families qualify for government financial assistance. The clinics have proliferated around the country since around 2000. In Texas, the biggest growth spurt occurred after the state in 2007 doubled the Medicaid reimbursement rates paid to dentists. Medicaid dental claims in Texas jumped 400 percent between 2005 and 2015, and they now total $1 billion a year.
Lawyers, dentists and pediatric patients’ parents have alleged the clinics, often propped up by corporate entities, overbill Medicaid and put at great risk the most vulnerable patients — children. Nowhere is the problem greater than in Texas, according to the U.S. Department of Health and Human Services. Its data shows 160 ongoing Medicaid dental fraud investigations in Texas, by far the most in the nation.
For the clinics, the lure is a government system that financially rewards dentists who perform multiple procedures. In formal complaints, lawsuits and public writings, critics allege the clinics rush children through dental treatment by heavy use of sedative drugs and with straitjacket-like restraint devices known as papoose boards.
“You either juice them or papoose them,” Dr. Michael W. Davis, a New Mexico dentist who has filed complaints with numerous state dental boards about such practices and generally has waged a campaign against these dental clinics, told the Chronicle.
The problem has attracted the attention of the federal government, the Texas attorney general and state board of dental examiners. Committee staffs of U.S. Sens. Max Baucus and Chuck Grassley produced a 2013 joint report about the “corporate practice of dentistry in the Medicaid program.” These corporate-run dental practices, it said, “over-emphasize bottom-line financial considerations at the expense of providing appropriate high-quality, low-cost care.” The report cites unnecessary dental treatments and serious trauma to young patients.
The report gives no data on the scope of the problem nationally, instead focusing on a handful of dental chains alleged to be engaged in risky dental treatment and fraudulent billing practices. Four of the chains operate in Texas, including two in Houston.
Texas is the only state that tracks adverse medical events that occur at dental clinics. Dentists have notified the Texas State Board of Dental Examiners of 550 hospitalizations and 86 deaths since 2010. The records of these notifications did not break down how many of these incidents involved Medicaid patients. The latest death at a clinic, a 14-month-old girl who was given anesthesia for a cavity filling, occurred in Austin in late March. Details about the clinic’s operation remain unclear, including if it treated mostly Medicaid patients. Clinic under probe
“What happened to Nevaeh Hall happens across this country all the time,” said Houston attorney Jim Moriarty, who represents the Hall family and has handled many similar cases. “Overtreating children and failing to properly treat them anesthetically, principally at corporate ‘Medicaid clinics’ seeking to maximize profits, is a disaster.”
Moriarty has secured settlements totaling more than $42 million on behalf of about 3,000 children, all of whom are alive and whose parents sought redress for alleged overtreatment or mistreatment at dental clinics. He said all the settlements involve children treated at “corporate clinics specializing in Medicaid patients.”
Jefferson’s Diamond Dental clinic, closed in January, focused on Medicaid patients and operated without corporate affiliation. The Texas Attorney General’s Office said it is investigating Diamond Dental for possibly defrauding Medicaid, Moriarty said. A spokeswoman for the attorney general would neither confirm nor deny that.
Nevaeh’s parents took her to Jefferson’s clinic in northwest Houston at the beginning of the year to stabilize the girl’s decaying teeth. Within an hour after Nevaeh was given a sedative and placed in a papoose board, her parents heard her cry out and rushed from the waiting room to see what appeared to be a seizure. Courissa said clinic staff assured her Nevaeh was fine and just needed to rest.
But Nevaeh’s patient records, provided to the Chronicle by Moriarty, show too much medication was given for her 30-pound body. They also show an ambulance wasn’t called to take her to the hospital until late in the afternoon, more than four hours after her vital signs worsened.
Moriarty contends Hall was “chemically and physically suffocated.”
Jefferson’s lawyer declined comment for this story, and Jefferson did not return a reporter’s repeated telephone calls.
In February, the Texas State Board of Dental Examiners temporarily suspended Jefferson’s dental license, ruling her continued practice of dentistry would constitute “a clear, imminent or continuing threat to a person’s health and well being.” A State Office of Administrative Hearings proceeding to decide whether to permanently revoke Jefferson’s license is scheduled for May 23-24.
Jefferson, who had been reprimanded by the dental board on two previous occasions, graduated from the University of MissouriKansas City dental school in 2003. She has been practicing dentistry in the Houston area since 2007. Her clinic closed early this year after the state temporarily suspended her dental license.
Dr. Dennis McTigue, an Ohio State University professor of pediatric dentistry and president of the American Board of Pediatric Dentistry, said that papoose boards have purposes in treating pediatric dental patients but are best used only in emergency situations.
“The routine practice of restraining a healthy child who has a lot of cavities but nothing urgent with them is wrong,” McTigue said. “It flies in the face of everything we believe about protective stabilization.”
McTigue, who acknowledges Medicaid dental clinics that overtreat children are a big concern, said the vast majority of irreversible injuries suffered in dental clinics occur because sedation was given improperly, some- times by a practitioner not adequately trained, and it wasn’t well monitored.
Mylesia Fulford, a former dental assistant at Diamond Dental clinic, said such standards of dental care were routinely violated when she worked at the clinic during two stints, from 2007 to 2008 and 2012 to 2014. She left well before Nevaeh’s January appointment.
In a lengthy statement taken by Moriarty and provided to the Harris County District Attorney’s Office, the state dental board and in an interview with the Chronicle, Fulford described a host of problems at the clinic: that Jefferson didn’t calculate sedative amounts based on a patient’s weight; that dental assistants performed procedures they weren’t licensed to perform; that most children were put in a papoose and many were heavily sedated as well; that procedures, often unnecessary, were added to the dental treatment plan to which parents had agreed; and that marketers were hired to solicit patients from households with Medicaid dental insurance.
“Medicaid is how Dr. Jefferson made a living,” Fulford said. She told the Chronicle and authorities that Jefferson “abused the system.” Ownership in question
The Baucus-Grassley report focused on dental practices affiliated with companies that purport to provide administrative support to dentists but often “own the dental clinics and have complete control over operations, including clinical care.” It calls the ownership structure “fundamentally deceptive,” hiding from state authorities “the fact that all rights and benefits of ownership actually flow to a corporation through contracts between the company and the ‘owner dentist.’ ”
The report’s findings are disputed by officials at the Association of Dental Support Organizations, the Virginia-based trade group for such dental-service companies.
Bill Head, a spokesman for the association, said the original criticism of such companies comes from competitors, dentists unable to spend as much time with patients because they are bogged down with administrative duties.
“Ultimately, only the dentist is responsible for the care provided to patients,” Head said. “It’s a red herring to say dentalservice organizations direct care. If they do, state dental boards should go after them for providing care without a license.”
The Texas board of dental examiners is awaiting guidance from the Texas Legislature on that very issue, said Kelly Parker, the agency’s executive director. Texas law requires that dental practices be owned by dentists.
In a September report to the state Legislature, the agency expressed concern about dentists “partnering with non-dentists to establish ‘sham’ ownership of dental practices functionally owned, maintained or operated by non-dentist entities.” According to the report, the agency’s concerns grew out of its recognition of “the spread of Medicaid fraud in Texas” and “the growth of dental business models that appear to focus on monetary gain rather than patient care.”
Moriarty estimated there are about 50 company owned dental clinics in Houston and probably half of them opened after the state doubled Medicaid reimbursement rates in 2007.
“We need to get the dental community to truly realize the threat these clinics represent,” the attorney said. “You’ve got children dying and being mistreated in dental clinics and no one knows what’s happening behind closed doors besides the dentists.”
There’s now movement in Texas in that direction. A state report has called for the Texas board of dental examiners to do more to protect dental patients from deadly sedation risks, noting that the agency lacks the authority and resources to routinely inspect dental offices — unlike their medical board counterparts in Texas and most dental boards in other states. The report recommended that the Texas Legislature in 2017 authorize the dental board to conduct such inspections and require dental practices to maintain emergency management plans.
For the Hall family, the state’s action unfortunately is too late. In 2014, Fulford and another Diamond Dental employee alleged to the state board of dental examiners that Jefferson was not complying with state dental care standards. The agency investigated the allegations but found no wrongdoing.