Medicaid Investigations & Dental Professional Defense

Defending Dental Professionals Against Texas Medicaid Investigations Since 1987

Hendershot Cowart P.C. has over a century of combined experience with medical and dental practice law. Our attorneys are well versed in Medicaid audits and investigations by the state and federal agencies responsible for oversight. We have helped countless clients protect their dental practice from claims of fraud and worked tirelessly to provide the support and guidance they need.

On This Page:

• Who Investigates Medicaid Fraud in Texas?
• What Are The Potential Consequences of a Medicaid Investigation?
• How Are Medicaid Fraud Investigations Initiated In Texas?
• What To Expect from a Texas Medicaid Investigation
• What Is Dental Medicaid Fraud?
• How Can I Protect Myself in A Medicaid Dental Fraud Audit or Investigation?
• Our Medicaid Fraud Defense Attorneys Are Ready to Help Your Dental Practice

The Texas Health and Human Services Office of Inspector General and the Texas Office of Attorney General work together to detect and prevent fraud, waste, and abuse in the Texas Medicaid program.

• In Texas, the Medicaid program is administered by the Texas Health and Human Services Commission (HHSC). HHSC conducts administrative reviews and data analysis to detect billing irregularities. Cases or reports of suspected fraud are referred to the HHSC’s Office of Inspector General (HHS-OIG) for investigation.
• Texas Medicaid Fraud Control Unit (MFCU) is a division of the Texas Office of the Attorney General (OAG). The OAG has broad authority to investigate and prosecute cases of Medicaid fraud under the Texas Medicaid Fraud Prevention Act. The MFCU conducts criminal investigations into fraud and abuse allegations against Medicaid providers, including dentists. The HHS-OIG and MFCU meet regularly to discuss individual cases and share information that may lead to administrative or criminal prosecution.
• Texas Civil Medicaid Fraud (CMF) Division is also a division of the Texas OAG but is distinct from the MFCU. The Civil Medicaid Fraud Division investigates civil allegations of unlawful acts against the Medicaid program. The Civil Medicaid Fraud Division is unique in that most of the cases derive from private whistleblower lawsuits in which the state is allowed to intervene.
• Medicaid Dental Maintenance Organizations (DMOs) administer Medicaid dental services. There are three Medicaid DMOs that serve Texas, and each is required to have fraud and abuse detection and prevention programs in place, as well as a Special Investigative Unit to investigate irregularities. They may also refer potential fraud cases to HHS-OIG or MFCU for investigation.

Under the Texas Medicaid Fraud Prevention Act, Medicaid providers that knowingly commit “unlawful acts” are subject to recoupments, financial penalties (treble actual damages, $5,500 to $11,000 for each violation, and costs of litigation), administrative sanctions (including mandatory suspension or revocation of a license, permit, certification, or state-provider agreement), and exclusion from the Medicaid program for at least ten years.

The consequences of Medicaid investigation can be serious. Call our Medicaid investigation defense attorneys at (713) 783-3110 to start preparing your defense.

Investigations are initiated through fraud hotlines, healthcare professional or patient complaints, or data analysis of billing patterns conducted by the Texas Health and Human Services Commission or DMOs.

Once a potential fraud case is referred or uncovered, HHS-OIG, the OAG, or the Special Investigative Unit of a Medicaid DMO will launch its investigation. This investigation may involve:

• Sending a letter (often via email) with a “request for client records”;
• Reviewing medical records and billing documentation;
• Conducting interviews with patients, providers, and other relevant parties;
• Using a Civil Investigative Demand to require a provider to produce documentation; or
• Subpoenaing additional records or evidence.

Medicaid dental fraud in Texas primarily involves dental providers or their billing contractors cheating the Medicaid system to get improper reimbursements.

Here is an example: A dental practice bills Medicaid for the treatment of cavities that do not exist or do not otherwise require treatment.

Other examples of fraudulent acts against Medicaid involving dental practices include:

• Falsifying a patient’s diagnosis to justify unnecessary tests;
• Requiring vendors to “kick back” part of the money they receive for rendering services to Medicaid patients (kickbacks may also include vacations, merchandise, etc.);
• Billing Medicaid for care given to patients who have died or who are no longer eligible;
• Improper prescriptions;
• Billing patients for services already paid by Medicaid; and
• Substandard work or abusive patient care.

In some cases, a dental practice’s billing contractor may be the entity conducting fraud. Nonetheless, the dental services provider remains liable for violations of state and federal law.

Seek legal counsel as soon as possible. Medicaid fraud investigations can result in millions of dollars in recoupments or restitution, financial penalties, individual or entity exclusions, reputational damage, and civil or criminal prosecution.

Our healthcare and administrative law attorneys are familiar with the Medicaid investigation process. We can open lines of communication and help you prepare your response to investigators.

Other ways our investigation defense attorneys can intervene in a Medicaid investigation to produce the best possible outcome include:

• Negotiating timelines for document requests and narrowing requests, if possible, to minimize your exposure and administrative burden;
• Shielding you and your staff from costly mistakes when communicating with investigators that may violate your rights or expose you to unnecessary liability;
• Conducting our own internal investigation to identify areas of potential noncompliance and hold the government accountable for investigative errors or oversteps; and
• Determining if the investigation is civil or criminal, which is essential when determining your defense;
• Negotiating a fair outcome and avoiding criminal prosecution, especially in parallel civil and criminal investigations (i.e. when both HHS-OIG and MFCU are involved).

Our team of legal professionals can assist with a range of Medicaid investigations or audits. We can provide strategic representation throughout the investigation to minimize the impact on your dental practice, professional license, and livelihood. We are also available to review your current compliance policies and programs to prevent audits and other regulatory attention.

Contact our experienced Houston Medicaid dental audit attorneys at Hendershot Cowart P.C. today.