Local Dentist Pleads Guilty to Medicaid Fraud Scheme

SPRINGFIELD, Mo. – Tammy Dickinson, United States Attorney for the Western District of Missouri, announced that an Independence, Mo., dentist who formerly practiced at clinics in Springfield, Mo., and Mountain Grove, Mo., pleaded guilty in federal court today to his role in a conspiracy to collect more than $167,000 in fraudulent Medi­caid payments for child patients of the clinics.

James R. Dye, 66, of Independ­ence, waived his right to a grand jury and pleaded guilty before U.S. Magistrate Judge David P. Rush to a federal information that charges him with health care fraud.

In his plea, Dye admitted to con­spiring with two others, who oper­ated clinics under the name All About Smiles and contracted with Dye to work at the All About Smiles dental clinics in Springfield and Mountain Grove. All About Smiles, which has now closed all of its clinics, also paid for the services of three other dentists; they are neither charged nor identified in court doc­uments.

By pleading guilty today, Dye admitted that he and his co-conspirators purchased orthodontic appliances, known as Ortho-Tain, for approximately $50 each. The Ortho-Tain device, which Dye pre­scribed to child patients, was an orthodontic appliance designed to straighten teeth without braces. However, Dye and his co-conspirators billed each appliance to Medicaid as a speech aid prosthesis for approximately $695 (the maxi­mum allowed).

Over a nearly five-year period, from Oct. 6, 2010, to Aug. 19, 2015, Dye and his co-conspirators sub­mitted 241 claims, for which they received reimbursement of $675 to $695 per claim, for a total of $167,090. Dye was the performing provider on 218 claims totaling $151,105. The other dentists were responsible for the remaining amounts.

The Ortho-Tain orthodontic appli­ance is not a speech aid prosthesis, according to today’s plea agreement, and therefore should have been pre-certified by Medicaid and billed using a different orthodontic code. (A speech aid prosthesis was a max­illofacial prosthetic used to replace a missing part of a patient’s palate, or hole in the roof of the mouth, such as with a patient having a cleft pal­ate.  Medicaid did not require pro­viders to obtain prior authorization for speech aid prostheses provided to eligible beneficiaries.)

Dye knew his patients did not qualify for and thus had not received prior authorization for orthodontic treatment, so he knew the Ortho-Tain products were not being billed and paid as orthodontic devices. Had officials administering Medicaid known the conspirators submitted claims for payment for orthodontic appliances that were represented to be speech aid prostheses, Medicaid would not have paid the conspira­tors’ claims.

Dye admitted that he and his co-conspirators knew Medicaid did not cover orthodontic services unless the Medicaid program’s requirements were met and they received pre-certification, which required review by a dentist/orthodontist employed by Medicaid. For that reason, the conspirators decided to bill the Ortho-Tain appliances as speech aid prostheses in order to bypass the pre-certification requirement.

The vast majority of the ortho­dontic appliances that Dye and co-conspirators billed as speech aid prostheses were Ortho-Tain ortho­dontic appliances, but they also billed other orthodontic appliances, such as retainers, as speech aid prostheses.

Under federal statutes, Dye is subject to a sentence of up to 10 years in federal prison without parole. Dye must forfeit $167,090, which was derived from the pro­ceeds of the health care fraud scheme, to the government. The maximum statutory sentence is pre­scribed by Congress and is provided here for informational purposes, as the sentencing of the defendant will be determined by the court based on the advisory sentencing guidelines and other statutory factors. A sen­tencing hearing will be scheduled after the completion of a presentence investigation by the United States Probation Office.

This case is being prosecuted by Assistant U.S. Attorneys Steven M. Mohlhenrich and Cindi Woolery. It was investigated by the U.S. De­partment of Health and Human Ser­vices – Office of the Inspector Gen­eral, the Medicaid Fraud Control Unit of the Missouri Attorney Gen­eral’s Office and IRS-Criminal In­vestigation.