Dental chain in spotlight after child’s death, separate settlement in fraudulent billing case

About Mary Otto

Mary Otto, a Washington, D.C.-based freelancer, is AHCJ's topic leader on oral health and the author of "Teeth: The Story of Beauty, Inequality, and the Struggle for Oral Health in America." She can be reached at mary@healthjournalism.org.

In Arizona, relatives of 2-year-old Zion Jay Gastelum are trying to find out why the toddler died after a recent dental appointment.

Zion’s parents took him to a Kool Smiles dental clinic on Dec. 16 for a crown and filling, according to an uncle, who spoke to KNXV-Phoenix.

“Somehow either during or after the process, it appears Zion stopped breathing,” reporter Mike Pelton noted in his Jan. 5 story.

Zion was transported to Yuma Regional Medical Center and then flown to Maricopa County, where he died Dec. 20, according to his family. The Maricopa County Medical Examiner’s Office is investigating the cause and manner of the child’s death, KNXV reported.

The child’s grandmother Norma Yarrito described him as “a lovely, lovely little boy.”

In response to a request for comment from KNXV, Kool Smiles issued a statement which read in part: “Our hearts are breaking for Zion’s family at this very sad time. Since Kool Smiles’ founding nearly twenty years ago, we have safely and compassionately provided needed dental care through more than 19 million patient visits. Our dedicated dentists, anesthesiologists and the rest of our Kool Smiles family join the community to mourn this tragic loss.”

But meanwhile, in more troubling news for the chain, more than 130 affiliated Kool Smiles clinics and a management firm have agreed to pay approximately $24 million to settle claims that they fraudulently billed state Medicaid programs for providing unnecessary crowns, pulpotomies and extractions to poor children.

In a Jan. 10 statement, the U.S. Department of Justice announced that it had settled allegations against the clinics and their dental management company Benevis LLC.

“Billing Medicaid programs for dental procedures that are not necessary contributes to the soaring cost of healthcare,” said Acting Assistant Attorney General Chad A. Readler of the Justice Department’s Civil Division in the statement. “When health care providers put vulnerable patients at risk by performing medically unnecessary procedures to achieve financial goals, we will take action,” Readler noted.

The case arose after several whistleblowers complained to federal authorities that the chain paid bonuses to dentists who met production goals that rewarded expensive and unnecessary treatments, Hartford Courant reporter Edmund H. Mahony wrote in a Jan. 10 story .

In response to the Courant’s emailed request for comment, a spokesman for Benevis, which provides the clinics with business management and administrative services, offered a statement defending Kool Smiles and denying any improper treatment.

“Importantly, the settlement does not include any admission or determination of wrongdoing by the companies, their employees or any Kool Smiles dentists. In fact, the companies strongly disagree with the government’s allegations,” the spokesman stated in part, describing the dispute as primarily stemming from a disagreement among dentists over levels of treatment.

“The investigation largely focused on professional disagreements between qualified dentists in determining the appropriate level and cost of the care,” the spokesman stated.

Kool Smiles clinics, located throughout 17 states, and Benevis agreed to pay the federal government and participating states a total of $23.9 million plus interest to resolve the allegations.

Of that sum, the federal government is expected to receive a total of more than $14 million, with an additional $9.6 million going to states. Three whistleblowers, former Kool Smiles employees Adam Abendano, Poonam Rai, and Robin Fitzgerald will receive payments of more than $2.4 million from the federal share of the settlement, according to the Justice Department.

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