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El Paso clinics under investigation stops orthodontics treatment for some of its patients

Some children are lucky enough to be born with straight, pearly whites, but every year, millions of American families find themselves spending big money on braces.

Braces in El Paso typically run around $5,500 for a three-year orthodontic term.
Medicaid does not pay for cosmetic procedures, but according to Texas Health and Human Services, Texas Medicaid has been paying for cosmetic orthodontics work for years.

Texas Medicaid spent nearly $500 million on orthodontic treatment for children from 2009 to 2010, according to state records.

That is more than all other U.S. states spent on Medicaid orthodontics combined.

The vast majority of the cases paid for by Texas Medicaid were cosmetic cases, an HHSC spokesperson said.

In response to a public outcry and an investigation exposing the spending by WFAA-TV in Dallas, HHSC stopped all payment to some of the highest billers of Texas Medicaid, which a spokeswoman says have committed fraud.

“If they find credible evidence of fraud, where it appears a provider knowingly submitted incorrect information about cases, they can put a payment hold on them,” HHSC spokeswoman Stephanie Goodman said. “And that’s what they’ve done in this case.

Medicaid does not pay for cosmetic orthodontics, only for cases where the child cannot eat or chew his food properly.

Such cases would be children with cleft palate, Down syndrome, or cases where the child has had severe facial trauma due to an accident.

Goodman says fraudulent claims were made, making cases appear more severe, so that they would pass through Medicaid’s approval process.

This scenario happened so frequently, eventually racking up a bill of nearly half-a-billion dollars in three years, Medicaid now admits its contractor reviewing the cases was negligent.

One local group of orthodontics clinics, currently under investigation, has now stopped treatment for around half of their patients.

“We’re in the midst of treatment! You’re just going to abandon my kid?” Erika Mendoza, mother of a Sun Orthodontix Medicaid patient said.

Marcos Mendoza, 12, had his braces put on by Sun Orthodontix almost a year ago.

His mother said his crooked teeth made it necessary for him to get braces, and she said a doctor at Sun Orthodontix told her the braces would be paid for by Medicaid.

Now that Sun has discontinued treatment to Marcos, Erika Mendoza says she is scrambling to find another orthodontist to treat him.

Sun Orthodontix, with four locations in El Paso, is among several orthodontia clinics being investigated for fraud by the Office of Investigative Affairs.

Sun’s location in Las Cruces is not included because the investigation is limited to the state of Texas.

In a statement provided by the company’s attorney, Frank Sheeder, Sun Orthodontix blames the mess on Medicaid for signing off on the treatments in the first place.

“Our orthodontists were required to submit forms, x-rays and photographs of the patient to Texas Medicaid before they were permitted to provide treatment,” the statement reads. “These abrupt changes make it impossible for our orthodontists, and for many others, to continue to serve children in the Medicaid program.”

In the meantime, patients like Marcos are scrambling to find new orthodontists.

ABC-7 called a number of Medicaid-accepting El Paso orthodontists to see if they are taking Sun Orthodontix transfer patients.

All of them said ‘no,’ except one orthodontist.

El Paso orthodontist Dr. Rick Black says he is already taking former Sun Orthodontix patients — reevaluating their cases, and resubmitting their claims to Medicaid.

We asked him what he would do if payment was suddenly cut off from a case he had initiated. “I think, Matt, you kind of get what you ask for — in other words, even in private practice, even though I’m a Medicaid provider and I had a small amount of Medicaid patients before this happened — I feel an obligation,” Black said. “When you start a patient, regardless of what happens, especially money, you are obligated to finish that patient.”

It is a practice that Sun Orthodontix is apparently unwilling to honor in Marcos’ case.

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