NEWS 8 INVESTIGATES
DALLAS — Nobody has ever died from crooked teeth, some orthodontists say.
Historically, straightening teeth with braces is viewed largely as a cosmetic procedure, done for cosmetic purposes.
Yet, last year, Texas taxpayers paid for braces for more than 120,000 children under Medicaid. The total bill was more than $184 million, which was far more than the next 10 states combined.
A News 8 investigation found that Navarro Orthodontix, which controls 11 clinics across the state, was paid more than $22 million in Medicaid last year. That's more than the entire state of California, which paid out $19.4 million.
All told, Texas paid out over $184 million for Medicaid orthodontics last year, which is nearly double the amount from 2008. The money is supposed to go for teeth determined to be so crooked they could handicap a child, usually between the ages of 12 and 19 according to state rules. Judging by the increased payouts, the teeth of Texas children are growing more crooked each year.
"There's a large population of people that are somehow qualifying for Medicaid treatment that seven years ago weren't qualifying," said Dr. Greg Greenberg, a Dallas orthodontist.
While the worsening economy has put more kids into poverty, it's also true that orthodontics is booming.
On Garland Road in Dallas, two clinics are paired off like gas stations across from one another. All Smiles Dental sits directly across the street from the Smiley Dental Clinic. Smiley's vans, used to pick up patients, prominently display "Medicaid Accepted" in their bright yellow paint scheme.
Last year, Smiley took in nearly $2 million in Medicaid through its affiliates in North Texas. All Smiles collected $7.5 million. Together, the two chains collected more than twice as much as the entire state of Illinois paid out last year.
In Tarrant and Parker counties, doctors Sheila Birth and Charles Stewart run six offices, and like all the clinics mentioned in this story, they employ several orthodontists. All told, they collected more than $5 million in Medicaid last year, according to state records. That's twice as much as all the providers in the state of Florida.
Birth declined to be interviewed on camera for this story. In e-mails, she pointed out that a lawsuit in Texas forced the state to expand its Medicaid coverage in 2007, and that states have differing criteria for Medicaid reimbursement, which makes comparison inappropriate.
Texas was successfully sued over Medicaid underpayment, dental care included, but orthodontic care was not part of the lawsuit. Texas specifically prohibits Medicaid reimbursement for cosmetic orthodontic care.
Critics say the state simply doesn't evaluate claims.
"There's no accountability," said Dr. Larry Tadlock, an orthodontist with a private practice who's also an associate professor at Baylor Dental School in Dallas.
Texas allows general dentists, as well as orthodontists, to deliver orthodontic care. What one dentist may diagnose as simply crooked teeth may be crisis teeth for another dentist. Crisis teeth get fixed at taxpayer expense under Medicaid, usually at about $2,200 per mouth.
"There's no checks and balances," Tadlock. said "There's no legitimated approval process."
Medicaid claims are processed by an outside contractor in Texas. According the the Department of Health and Human Services, claims are rejected only if paperwork is incomplete, not on a standard of medical evaluation.
A dentist, the state says, oversees a team of four people that do not have dental backgrounds. The dentist consults on close calls. Each mouth gets a score. A score of 26 or more on a standardized rating sheet gets Medicaid dollars. But, orthodontists say there's pressure to push the score when there's money at stake.
"Any way you fill out that sheet will be approved," said one orthodontist who has worked in several high volume clinics and asked not to be identified. "Providers use that (evaluation) as an excuse to lie on that sheet because there's no checks on that sheet."
The state depends on the attorney general to prosecute Medicaid orthodontic abuse, and the AG has not done so in the last two years. The Department of Health and Human Services is aware of a potential problem.
"Dentistry is an area we've been concerned about for a long time," said Stephanie Goodman, of HHS. "And for whatever reason, we've had more trouble there than in other parts of Medicaid."
Many of the state's highest-billing orthodontists made more money last year than the year before.
Navarro Orthdontix collected $7 million more last year than the year before. Owner Dr. Carlos Navarro did not respond to phone calls and a visit to his office. Navarro's attorney, Mike McCue, said Navarro "strives to follow all state and federal requirements."
Smiley Dental Clinic and All Smiles Dental did not respond to phone calls.