Wednesday, October 4, 2023
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Getting Medicaid in Texas Is Like Pulling Teeth

DALLAS (CN) - A health care administrator delayed thousands of orthodontic approvals under Medicaid by employing just one dentist to review Texas applications, such disastrous understaffing that dentists - but not the private company - were accused of fraud for working without prior authorization, seven dentists claim in court.

The lawsuit from Dr. Paul Dunn, DDS, is typical of the seven dentists' complaints, all filed in Travis County Court.

The dentists claim that ACS State Healthcare committed thousands of dental practice violations by having unlicensed "dental specialists" give prior authorizations for orthodontic procedures rather than dentists.

ACS employed just one licensed dentist to evaluate requested orthodontic services for Medicaid to cover in Texas, Dunn claims.

ACS and the Texas Medicaid Healthcare Partnership are dbas for Xerox State Healthcare LLC, a Delaware corporation.

"It is now known that ACS failed to employ adequate medical professionals for staffing and managing the orthodontic prior authorization responsibilities," Dunn's 19-page complaint states. "ACS employed only one licensed dentist from 2004 to 2011, which was far short of the manpower necessary to handle the review of tens of thousands of orthodontic prior authorization requests every year. ACS could not reasonably have expected to handle such a workload by employing only one dentist."

The plaintiffs say the unqualified specialists were a breach of ACS' contracts in place and of the Dental Practice Act.

"It is believed these unlicensed ACS 'specialists' rendered tens of thousands of prior authorization approvals/medical opinions in violation of Texas law," Dunn's complaint states. "ACS was paid by the state for each prior authorization decision that was made. It is believed that ACS employed unlicensed 'specialists,' rather than licensed Texas dentists, as a profit-generating measure."

Dunn claims that his dental practice was crippled when the Texas Office of Inspector General conducted audits that concluded that "most, if not almost all" of prior authorization requests deemed medically necessary from 2009 to 2012 were not actually "evaluated" at all by ACS.

"Therefore, the OIG opened fraud investigations against each of the top 25 [dental] providers, including Dr. Dunn, which has caused more injury and damages to him," the complaint states.

"Stated differently, ACS issued its approvals through a process that gutted the state's belief in the accuracy of ACS' decision, and the OIG punished the providers instead of ACS."

The OIG later imposed a "payment hold" against Dunn, freezing Medicaid payments in spite of his participation in Medicaid.

"As a result of the payment hold, Dr. Dunn was required to make significant financial concessions and changes to his business," the complaint states. "Dr. Dunn also engaged legal counsel to defend himself from the OIG's claims, at a significant expense that continues today."

ACS could not be reached for comment Tuesday evening.

The plaintiffs seek actual and punitive damages for fraud, breach of contract, negligence and negligent misrepresentation.

They are represented by Jason Ray with Riggs, Aleshire & Ray in Austin.

Also suing, in three other complaints, were M&M Orthodontics PA; Dr. Scott Malone, DDS; Dr. Diana Malone, DDS; Antoine Dental Center; Harlingen Family Dentistry, P.C.; and Dr. Juan Villarreal, DDS. All sued ACS State Healthcare LLC.

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