Welcome to the Pondera FraudCast, a weekly blog where we post information on fraud trends, lessons learned from client engagements, and observations from our investigators in the field. We hope you’ll check back often to stay current with our efforts to combat fraud, waste, and abuse in large government programs.
Earlier this week, I was surfing one of Pondera’s internal messaging boards when I came across a photo of some painted rocks depicting flying pigs with multi-colored unicorn horns. It seems that one of our investigators is also a part-time artist. I must admit that I was confused by the subject matter. This is the response that I received to my question about the rocks:
Within Pondera’s Special Investigations Unit, you have to earn the flying pig rock by accomplishing something that others might consider implausible, so that they’d say “that’ll happen when pigs fly”… but more than that, you also have to do it like only a beautiful, magical unicorn could do it.
This is absolutely one of the most unexpected and satisfying things I’ve discovered in all my years in business. This tradition explains so much about Pondera’s success. We have a team of incredibly successful and dedicated people that continue to work on doing what many previously thought impossible. They do it themselves with only broad guidelines from the management team (hence my not knowing about the “pigacorn”). And they have fun while doing their work, taking pride in knowing how truly important it is.
While I continue to take pride in the success that Pondera is having fighting fraud alongside our clients, my recent discovery serves as yet another reminder of what makes this company go (dare I say fly?). I often say that everyone at Pondera left something great to join our team and align behind our mission. With people like that, I expect a lot more flying pigs and a lot less fraud.
A recent spate of high profile arrests of dentists is drawing attention to an often-overlooked segment of Medicaid fraud. Some unscrupulous dentists are exploiting gaps between what private insurers reimburse versus what Medicaid will pay for. Others are just brazenly breaking the law to rip off state Medicaid programs.
Consider these recent charges brought against dentists:
An Anchorage, AK dentist was charged with 10 felonies. His “care” included performing a tooth extraction while videotaping himself on a hoverboard. Naturally, he had to text the video to friends. He is also accused of giving expensive, and unnecessary, IV sedations to Medicaid patients and then performing unneeded procedures on his passed-out patients. Since private insurance rarely pays for IV sedation, he only performed this fraud scheme on his Medicaid patients.
A Fairfield, CT dentist who saw mostly elderly and indigent patients is accused of ripping off more than $900,000 from Medicaid by billing for services that he never performed. One hint that he may have not been acting honestly: he billed for both a cavity filling and denture procedure on the same tooth!
An Atlanta dentist was sentenced to 18 months in prison earlier this year for defrauding nearly $1,000,000 from Medicaid. Her unique talent included the ability to perform dental procedures in Atlanta while she was traveling out of the country.
Unfortunately, these cases simply support our premise that fraud will exist anywhere substantial amounts of money are exchanged in complex billing and regulatory environments. These, and other similar cases, serve as a warning that we must monitor literally every medical specialty reimbursed by Medicaid.