In the wake of a $23.9 million Medicaid fraud settlement between the U.S. Department of Justice and children’s dental clinic chain Kool Smiles, Dale G. Mayfield—Chief Dental Officer at Kool Smiles—was asked to step down from his position with the Georgia Board of Dentistry by Gov. Nathan Deal.
Through his position on the Board, which he held since February 2016, Mayfield had the power to influence how dentists were licensed and regulated throughout Georgia.
However, it’s unclear why Mayfield was allowed to serve on the Board at all, considering that the Georgia Department of Community Health began investigating Kool Smiles for misconduct in 2007 and the federal government filed a False Claims complaint against the company in 2013. Mayfield joined Kool Smiles in 2006.
Kool Smiles had long history of Medicaid misconduct
The first Kool Smiles location opened in 2002 in DeKalb County, Ga. The dental chain, which now has locations in 16 states, specializes in providing dental care for underserved and low-income children, most of whom are receiving Medicaid.
Since Medicaid reimburses dental offices at a lower rate than private insurance companies, Kool Smiles admits that their offices must be more efficient to make their business model feasible. But former employees allege that the company took it too far by pressuring them to bill as much as possible and meet monthly treatment quotas.
In return, dentists who billed the most were given incentives like gift cards, iPods, and massages.
The consequences of these questionable policies were uncovered during audits performed by state Medicaid officials and the Georgia Department of Community Health.
In 2007, auditors reviewed 6,600 patient files and found 219 cases where dental work did not meet quality standards and 427 cases where dental work was altogether unnecessary. By 2009, the problem was worse: auditors found 1,024 issues in just 248 files.
The reviews also uncovered an “unusual” pattern of restraining patients. And auditors discovered that Kool Smiles patients were five times more likely to receive stainless-steel crowns—which are generally not considered a first-line treatment but do fetch a higher Medicaid reimbursement rate.
The results of the audits were so alarming that two of Georgia’s Medicaid networks moved to end their contracts with Kool Smiles.
Even after two audits and scrutiny from health departments in Georgia and other states, leadership at Kool Smiles, which included Mayfield as Chief Dental Officer, did nothing to improve the problems in their clinics.
Finally, in 2013, the Department of Justice caught wind of Kool Smiles’ misconduct and filed a False Claims complaint against the company in eight states, including Georgia.
Kool Smiles will pay $23.9 million in Medicaid fraud settlement
In January 2018, the Justice Department settled with Kool Smiles. As part of their agreement, Kool Smiles will pay $23.9 million on allegations of submitting false Medicaid reimbursement claims for procedures that were never done.
The federal complaint echoed much of what the Georgia audits had found, alleging that Kool Smiles preyed on low-income children and squeezed as many Medicaid dollars as it could out of them. The lawsuit asserted that:
- Kool Smiles regularly upcoded treatments, inflating the services they provided and billing for treatments that were never done at all.
- Dentists defaulted to stainless-steel crowns rather than using more appropriate fillings that wouldn’t have made Kool Smiles as much money.
- Dentists were pressured to perform unnecessary baby teeth root canals and tooth extractions, another way they increased reimbursement rates.
- Oftentimes, painful procedures were performed with insufficient anesthesia, and children were restrained with “papoose boards” while their parents were told to wait outside to “keep hidden the child’s suffering.”
Mayfield was called out specifically in the lawsuit for creating and implementing these harmful policies.
Dale Mayfield influenced Georgia dentistry for two years
It’s uncertain why, in the midst of a $23.9 million-dollar fraud lawsuit, the State of Georgia appointed Mayfield to its Board of Dentistry when the allegations against Kool Smiles (and Mayfield’s involvement in them) were well known.
A Santa Fe-based dentist and industry consultant named Michael Davis called it an example of “the fox guarding the henhouse.”
The Atlanta Journal Constitution reports that during the two years Mayfield served on the Board, members handed down 135 orders, 18 of which were confidential. There’s no way to know how those orders will impact Medicaid patients in Georgia or what Mayfield’s involvement in them was. However, now that Mayfield has been removed from his position, there’s room for a dentist with integrity to take his place.
If you have inside information about dentistry offices or other healthcare providers cheating Georgia Medicaid, or Medicare, we want to hear from you – you can stop the fraud, help taxpayers, and you may be eligible for a sizeable whistleblower reward. CONTACT