Doctor identity theft is not a victimless crime

Some dental employers have falsely asserted that doctor identity theft is a victimless crime and no one is harmed. They claim reasonable dental services are rendered to patients regardless of the provider’s identity, which claims are billed through. They allege, “No harm, no foul.” This does not comply with federal and state statutes and for solid reasons.

Under federal statute 18 U.S. Code § 1028A, conviction for aggravated identity theft is a criminal felony and carries a two-year term for imprisonment. An individual whose identity is misappropriated may be complicit in criminal activity or be an unknowing victim.

Dr. Michael W. Davis.

On April 14, 2023, a Chelmsford, MA, dentist accepted a guilty plea for his role in a Medicaid fraud scheme. His co-conspirator was earlier disbarred as a provider in MassHealth (the state’s Medicaid program) because of significant concerns involving the quality of his dental care delivered to patients.

From 2014-2018, this Chelmsford doctor agreed to allow the disbarred dentist to bill MassHealth under his name and credentialing. In exchange, the now-convicted dentist received a percentage of collected government money.

Disadvantaged Medicaid-eligible patients received treatment from a problematic clinician. Taxpayers were cheated by not having their funding go toward reputable healthcare services.

More frequently, associate dentists are completely unaware if or when their employer steals their identity.  On April 12, 2023, Florida Chief Financial Officer Jimmy Patronis announced five arrests in a largescale Medicaid fraud scheme.

The accused are part of a dental service organization’s (DSO) management team. The group allegedly committed felonies related to identity theft, organized scheme to defraud, insurance fraud, and grand theft by allegedly using a former dentist’s credentials to defraud insurance companies and Medicaid managed care organizations (MCOs) out of more than $3.1 million.

The companies allegedly defrauded include DentaQuest, MCNA, Liberty, Sunlife, and Humana. The DSO issued the following press release immediately following the arrests of five persons in their management team:

“AC Pediatrics Dentistry & Orthodontics is involved in an ongoing legal dispute with the former founders of the company, and in a related investigation from the Florida Bureau of Investigation. Despite maintaining complete innocence from any criminal wrongdoing, and actively cooperating in the process, we lament recent developments which led to the arrest of five company executives. Sadly, the origin of this ugly debacle traces to disgruntled former employees who were removed from their roles in 2022, and are now fixated on tearing down the company they worked for, regardless of the human toll. The accusations pertain to administrative technicalities from which we had zero financial benefit, and which harmed absolutely no one. As such, AC Pediatrics continues to actively work with the State to demonstrate company and individuals’ innocence. We operate with the utmost integrity, and take these charges very seriously. We strongly refute the accusations being leveled against us and look forward to a full exoneration as the legal process unfolds.”

Local South Florida media news outlet Local 10.com reported that investigators with the Florida Department of Financial Services’ Bureau of Insurance Fraud dubbed the case the “Tooth Fairy heist.”  According to investigators’ report, a husband and wife dental team sold their practice to a DSO in 2020. The DSO fired the original owner dentists in 2022.

The report goes on to state that the pair had purportedly raised objections to the company’s nondentists “trying to impose and implement operations” that violated Florida statues related to the proprietorship of clinics by nondentists. Allegedly, the fraud began shortly after dismissal of the original dentist owners by the DSO.

Additionally, the report alleges that the five arrested DSO executives asked six associate (employee) dentists to allegedly “accept a new billing process” in which procedures done by unlicensed auxiliaries “would be signed off by the existing credentialed doctors even though they did not administer or supervise the treatments.”

The dentists allegedly “disagreed with this process because they weren’t supervising, would not be compensated, and did not want their licenses used without their direct administration.” One dentist allegedly did sign off on billing services “she did not perform, but only for her and the doctors she agreed to supervise.” It is unclear if this alleged accomplice doctor will face future charges.

Allegedly, during a set time frame, every pediatric dental patient under age 6 was purportedly billed for an additional code -- D9920 -- for “behavior management” at one of the DSO’s facilities. This practice was allegedly done without the consent or knowledge of the treating doctors. The objective was allegedly to increase production to meet goals required for management bonuses.

Doctor identity theft is a significant and growing problem within the dental industry. Dentists may be unreasonably asked by their employers to “go along to get along” and risk future code violations and discipline that will be reflected in their dental licenses.

Some dentists are willing criminal accomplices. Others opt to play along, with little or no financial compensation. Such dentists often struggle under monstrous student debt loans and require employment to meet monthly bills. They may easily bow to the demands of their employers.

Most dentists, as demonstrated in the recent investigation of the Florida DSO, will not knowingly be party to unlawful activities. However, the investigation process may involve an ethical doctor’s time, effort, legal costs, and stomach lining.

A DSO’s unlawful billings through an unsuspecting doctor’s national provider identifier may also result in investigations by the U.S. Internal Revenue Service for apparent unreported income and potentially fraudulent Medicaid or insurance billing. 

Doctor identity theft can often be damaging to the dentists victimized. Such activity also defrauds the insurance and MCO industries. However, the primary casualty of doctor identity theft is the public welfare.  

Dr. Michael W. Davis practices general dentistry in Santa Fe, NM. He also provides attorney clients with legal expert witness work and consultation. He can be reached at [email protected] or SmilesofSantaFe.com.

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.