Massachusetts Sues Orthodontist For Keeping Children In Braces Longer Than Medically Necessary

The Massachusetts Attorney General announced on March 1, 2021 that a lawsuit has been filed against orthodontist Dr. Mouhab Z. Rizkallah, DDS and two companies he owns through which he operates six orthodontic practices in Massachusetts, alleging that since November 2013, the defendants instituted a series of illegal policies and practices with the intent to defraud MassHealth by fraudulently submitting millions of dollars in false claims, including by keeping children in braces for longer than medically necessary and deceptively billing for mouth guards.

The AG’s complaint alleges that Dr. Rizkallah instituted various practices to increase the amount of money collected from MassHealth, regardless of whether the services were medically necessary. For example, Dr. Rizkallah allegedly kept his MassHealth patients, mostly children, in braces longer than medically necessary so he could bill MassHealth for more money. To do this, he often put braces only on a child’s top teeth at the beginning of comprehensive orthodontic treatment, even when there was no medical justification for delaying putting braces on the bottom teeth. This significantly extended the patient’s treatment time and increased the amount of money collected from MassHealth.

The AG’s lawsuit further alleges that the defendants instituted a practice of billing MassHealth for custom-fitted sports mouth guards for MassHealth members receiving comprehensive orthodontic treatment at Dr. Rizkallah’s practices. Under MassHealth regulations, a claim for payment for an athletic mouth guard is payable by MassHealth only if the mouth guard is custom-fitted and the member is engaged in a contact sport. However, the AG’s investigation reportedly determined that many patients did not request, need, or receive these mouth guards, and if they did receive them, they were not custom-fitted.

The AG’s lawsuit alleges that when provided at all, the mouth guards given to patients were the type sold in retail stores for $9.99 and Dr. Rizkallah allegedly instructed his staff to cut the price off the packaging before giving it to the patient. Dr. Rizkallah billed MassHealth between $85 and $95 for each mouth guard. During this time, the AG’s Office alleges that MassHealth paid Dr. Rizkallah’s orthodontic practices more than $1 million for these mouth guards.

The AG’s lawsuit also alleges that the defendants routinely and intentionally circumvented MassHealth regulations requiring medical necessity and prior approval for comprehensive orthodontic treatment. The AG’s Office alleges that for certain MassHealth patients, the defendants obtained prior approval by intentionally misrepresenting to MassHealth that the patients had previously been receiving comprehensive or interceptive orthodontic treatment from another provider or had previously had their treatment covered by an insurer other than MassHealth.

The AG’s Office alleges that this conduct violates the state False Claims Act and the state Medicaid False Claims Act; constitutes a breach of contract by the two companies; and resulted in the unjust enrichment of the defendants. The lawsuit seeks treble damages and civil penalties.

Source

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This entry was posted on Tuesday, March 23rd, 2021 at 5:23 am. Both comments and pings are currently closed.

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