Dental News

Massive Texas Medicaid dental claim fraud case reaches final conclusion.

July 09, 2018

A case filed back in 2014 was finally put to rest after the Texas Supreme Court found Xerox responsible for $1 billion in fraudulent Medicaid payments that the company made while overseeing pre-authorizations for Texas patients’ dental procedures.

It all started when a state audit in 2008 uncovered that Texas Medicaid and Healthcare Partnership, a subsidiary of Xerox, had one dentist on staff who reviewed roughly 10% of orthodontic claims. Employees without dental licenses reviewed the remaining 90%. At the time, the contractor argued that its agreement with the state did not required routine orthodontic claims to be reviewed by a dental professional.

But a 2014 federal audit raised additional red flags when it was discovered that Texas Medicaid payments for orthodontic procedures had grown about 3,000 percent between 2003 to 2010 (from $6.5 million to $220.5 million) while program enrollment grew only 33 percent during the same period. The numbers weren’t adding up.

Quite a bit of finger-pointing ensued, with state attorneys accusing providers of submitting false pre-authorizations, and providers contending that Xerox and the state should not have automatically approved corresponding payments without alerting them that something was wrong.

In the end, the recent 25-page decision from the Texas Supreme Court upheld the Texas Court of Appeals’ ruling that Xerox was ultimately responsible for the billion dollars in fraudulent Medicaid payments.

If you’re a dentist in Texas and you were wondering why orthodontic procedure coverage had declined dramatically under the state Medicaid plan, look no further.