OLYMPIA — Attorney General Bob Ferguson today announced that his office is recovering $3.35 million from Sea Mar Community Health Centers, stemming from allegations Sea Mar improperly billed Medicaid for thousands of dental appointments.
After a two-and-a-half-year investigation, the false claims unit of the Attorney General’s Medicaid Fraud Control Unit raised concerns that Sea Mar had overbilled Medicaid more than $3 million for dental services between 2010 and 2014.
The Attorney General’s Office alleged that fluoride treatments, which could have been performed by dental assistants as part of a patient’s regular six-month checkups, were instead billed as stand-alone appointments with a dentist or hygienist.
Fluoride treatments should be billed on a fee-for-service basis, usually between $13.25 (for 6-to-19-year-olds) and $23.41 (for younger children). Bills from Sea Mar instead were sent to Medicaid as “encounters,” indicating patients were seen by a dentist or hygienist, with a typical fee of $180. Medicaid billing rules dictate that in order to bill for an encounter fee, the dental service provided must require a dentist or dental hygienist to warrant the higher cost.
The false claims unit alleged that Sea Mar’s billing for these appointments also exceeded the number of dental exams allowed per patient under Medicaid, without any documentation of the findings of such exams or that the exams were actually performed.
“Without exception, providers who participate in our state’s Medicaid program must accurately bill for and document services provided,” Attorney General Bob Ferguson said. “I’m pleased my office was able to recover the excess taxpayer funds that went out the door so this money can go back into health care for those in need.”
The agreement also resolves a pending case filed by Sea Mar in federal district court. Sea Mar cooperated fully in the investigation.
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The Office of the Attorney General is the chief legal office for the state of Washington with attorneys and staff in 27 divisions across the state providing legal services to roughly 200 state agencies, boards and commissions. Attorney General Bob Ferguson is working hard to protect consumers and seniors against fraud, keep our communities safe, protect our environment and stand up for our veterans. Visit www.atg.wa.gov to learn more.
Peter Lavallee, Communications Director, (360) 586-0725; PeterL@atg.wa.gov