Fluoride Action Network

Sea Mar settles lawsuit for $3.5 million

Source: North Country Outlook, Vol. 8 No. 17 | January 28th, 2015 | By Christopher Andersson

Sea Mar Community Health Centers has paid $3.35 million to the Washington state Attorney General’s office to settle an issue of improper dental billing

The Sea Mar health centers are located all across the state, including one local clinic in Marysville which does provide dental services.

The Attorney General’s office alleged that Sea Mar has overbilled the state’s Medicaid thousands on dental appointments over the last four years.

“Medicaid funding is limited in nature and any overbilling prevents other people from getting the healthcare that they need,” said Peter LaVallee, communications director for the Attorney General’s office.

Sea Mar officials say that multiple audits in years past from Washington state agencies never had problems with the organization’s Medicaid billing.

Michael Leong, legal affairs director and senior vice-president at Sea Mar, said there was no misrepresentation in the billings, that “the State accepted these billings and paid them consistently over the years,” and “that periodic audits did not raise this as an issue.”

Sea Mar serves more than 216,000 patients each year and more than 95 percent of them are low-income.

The major issue was over fluoride treatments, which could have been performed by dental assistants as part of regular checkups, according to the Attorney General’s office. Instead, Sea Mar billed them as stand-alone appointments, according to the Attorney General’s office.

“SeaMar accounted for well over half of Medicaid fluoride treatment billing in the state,” said LaVallee.

They say fluoride treatments should be billed for $13.25 to $23.41 instead of separate encounters, which come with a typical fee of $180.

Leong said that usually fluoride treatments were applied during regular checkups at Sea Mar, however sometimes their dentists would require a treatment plan with multiple fluoride treatments, which would have to spaced out over multiple appointments.

He added that the $180 reimbursement from the state is not necessarily a windfall for Sea Mar. “Many times that reimbursement rate of $180 is far less than the costs of providing treatment, i.e. root canals,” he said.

Sea Mar cooperated fully in the investigation according to the Attorney General’s office.

The $3.35 million agreement also resolves a pending case filed by Sea Mar in federal district court.

The Attorney General’s office had demanded $72 million from Sea Mar, and the two organizations decided to settle with $3.35 million, about half of the alleged damages from Sea Mar’s billing.

An additional $300,000 was paid to a whistleblower by Sea Mar in the settlement.

Leong maintains that Sea Mar did nothing improper, however the settlement was less expensive than continued litigation, he said.

He said that dental patients will not see any change of service from Sea Mar. “In the instance of Sea Mar’s pediatric dental patients who are at risk for developing caries, multiple fluoride treatments may be a part of the treatment plan regardless of whether the state will reimburse for the treatment,” he said.

LaVallee said the Attorney General’s office is glad it was able to regain some funds for the state. “We are happy to get these funds back into the Medicaid system,” he said.