SPRINGFIELD, Mo. (CN) - A dentist claims in a class action that Missouri retaliated against him for challenging its denial of Medicaid claims for dentures - and that one state official claimed that "teeth are not necessary to eat."
James Dye, DDS, sued Missouri Department of Social Services Director Brian Kinkade, the director of its Medicaid Audit and Compliance Unit Jessica Dresner, and Dresner's "subordinate," Cindy Lenger, on Wednesday in Federal Court.
Dye sued Kinkade in his official capacity, Dresner and Lenger as individuals and as officials.
Dye claims he incurred "massive legal bills and expenses" after an audit of 500 patient files conducted with less than 24 hours notice.
He claims, among other things, that Lenger "made up the term 'adults with limited benefits'" to reject Medicaid claims for dentures; that there are "no exceptions" to this; that Lenger said "teeth are not necessary to eat," and that she said all this in "sworn testimony in a deposition and at an administrative hearing."
He claims that Langer and/or Dresner also stated that "letters from the physicians stating that dentures were a medical necessity for plaintiffs' patients were not 'letters from a physician stating the medical necessity of the dentures.'"
Dye claims he was forced to close two of his dental offices as a result of the denials and retaliation.
Dye says that Lenger referred him for investigation of unethical billing when he submitted Medicaid denture claims which were ineligible under rules of a "new," unauthorized manual Social Services uses to determine Medicaid benefits. He claims that Social Services is using the new manual instead of an earlier, state-authorized version so that it can deny Medicaid reimbursement for adult dentures as a way to trim costs.
Dye claims the new manual contains inconsistent provisions on dental services and has a "chilling effect" on dentists, who will choose not to provide denture services to qualified Medicaid recipients out of fear that the state will deny "all medically necessary denture claims, no matter what."
Under federal Medicaid laws, states must provide dental benefits to children covered by Medicaid but individual states can choose whether to provide dental benefits to adults. Missouri provides dental services to adult Medicaid recipients under "limited circumstances" outlined by the Missouri Department of Social Services.
Dye calls the defendants' actions arbitrary and capricious and claims that he and other Missouri dentists have been denied more than $1 million in claims.
Dye seeks class certification, declaratory judgment that the unauthorized dental manual cannot be used to determine Missouri denture claims, and an injunction.
He is represented by Craig Heidemann, with Douglas, Haun & Heidemann, of Bolivar.