Preston Oral Surgery: Medicaid Billing Claims and a Later Integrity Breach

The Preston Oral Surgery settlement set a $2.2 million obligation to resolve allegations of unsupported or unnecessary North Carolina Medicaid oral-surgery claims and claims contrary to state coverage policy. The disputed bills covered oral evaluations, anesthesia time, nitrous oxide and alveoloplasty. Someone who knows the treatment notes or anesthesia records can explain what those claims represented, while someone responsible for compliance may recognize the separate failures that followed the settlement.

The agreement took effect on August 21, 2015. It resolved disputed claims involving the surgeon and the professional association doing business as Preston Oral and Maxillofacial Surgery. Two whistleblowers brought the case.

The later integrity-agreement breach concerned the surgeon’s failure to carry out required compliance work. That distinction matters inside the practice: the person who understands an anesthesia bill may be different from the person who knows whether staff received training or a report reached the inspector general.

The Medicaid Claims Behind the Settlement

Federal and North Carolina authorities alleged improper Medicaid claims from January 1, 2008 through December 31, 2011 for detailed oral evaluations, additional deep-sedation or general-anesthesia time, nitrous oxide and alveoloplasty. The settlement resolved claims under the federal False Claims Act and North Carolina’s own false claims law.

Those service descriptions give the billing allegations their substance. An evaluation claim describes clinical work, while an additional anesthesia-time claim also makes a representation about duration. For an insider, the useful connection is between the claim submitted to Medicaid and the record of the service behind it. A completed procedure note and the billing entry each tell part of that story.

We would examine the evaluation documentation alongside the billed evaluation, and the anesthesia record alongside the additional time charged. For the nitrous oxide and alveoloplasty claims, we would connect the billed service to the clinical account and the coverage policy applicable to it. These are different questions within the same oral-surgery case, and someone who worked on the records may be able to explain where the claim departed from the care.

What Happened After the Settlement?

On February 10, 2016, the surgeon paid a separate $10,000 penalty for failing to comply with his integrity agreement. The HHS Office of Inspector General’s notice identifies failures involving a posted hotline notice, training, employee and contractor screening, and an implementation report. This payment concerned the compliance duties that followed the billing resolution.

The required notice was supposed to display the inspector general’s fraud-hotline number prominently where patients and people covered by the agreement could see it. The other failures involved required staff training, screening employees and contractors against federal exclusion lists, and a late implementation report.

We find it absurd that the follow-up failures reached all the way down to putting up a notice. After agreeing to resolve the Medicaid billing allegations, the surgeon failed to meet even that visible obligation. These were concrete tasks with visible results inside the practice. Staff responsible for training, hiring or reporting could know whether those results existed, quite apart from whether they understood an oral-surgery billing code.

Sarasota Pain Associates Faced Similar Follow-Up Failures

Sarasota Pain Associates and its physician agreed to a $750,000 Medicare settlement announced on February 25, 2014. The Justice Department alleged that they billed high-level office visits for comprehensive examinations that did not occur, in addition to separately paid scheduled procedures. Former nurses brought that whistleblower case, and the resolution included an integrity agreement requiring independent external review and training.

The inspector general later recorded a penalty for a late quarterly claims-review report. The parallel is the unfinished work after resolution: the government settled allegations about clinical billing, and the agreement left specific duties for people inside the practice to perform.

Evidence of Oral Surgery Medicaid Billing Fraud

Useful evidence of physician billing fraud connects the claim with the treatment date, the service documented and the people who know how the bill was produced. The 2017 Journal of AHIMA article Busting Bad Medicine: a Call to Action Addressing Healthcare, Fraud, Waste, and Abuse recommends checking the treatment date, treatment type and nurse or physician signature against the patient’s health record. The article also emphasizes witnesses who can explain what they know about the fraud.

Applied to these allegations, that means understanding how an oral evaluation or anesthesia entry became a claim for payment. A clinician may explain the care recorded, while a billing employee may explain the service and time submitted to Medicaid. We work with that account to connect what happened in the office to what the government was asked to pay.

The later compliance work has its own records: training attendance, screening results and the implementation report’s submission history. We would compare those records with the duties the inspector general identified and with the account of the person responsible for doing the work. Someone who arranged the training or prepared the report can explain when the task was completed and what was submitted.

The AHIMA article connects staff training with a workplace where employees can trust the integrity of the services they provide. Here, training was also a concrete obligation the surgeon failed to fulfill.

How Much of a Settlement Does a Whistleblower Get?

The Preston agreement provided the whistleblowers a 20% share of settlement money received. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

The settlement’s initial $900,000 payment included credit for remaining withheld funds. The agreement scheduled the remaining $1.3 million principal in installments.

You Know the Care or the Compliance Work

If you know how oral-surgery claims were created or why promised compliance work went undone, speak to one of our Whistleblower Experts about those claims or compliance failures. We develop the case with you and bring in physician fraud whistleblower lawyers who understand Medicaid billing and practice compliance. We stay beside you throughout the process to build your strongest Medicaid whistleblower case.