Wednesday, May 30, 2012

The Morning Drill: May 30, 2012

Meet Dr. Tom Kalili, dentist

Good Wednesday morning!

On to today's dentistry and health headlines:

Beverly Hills Dentist Accused of Insurance Fraud in Excess of $300,000

A Beverly Hills dentist was arrested Friday on a 101-count felony complaint alleging insurance fraud exceeding $300,000 in losses, according to the Los Angeles District Attorney's office.

Tom K. Kalili, 57, is charged with grand theft and tax evasion with an excessive-taking allegation. Kalili is expected to appear for arraignment early next week.

Kalili owns and operates Beverly Hills Medical Suites, a dental office. A glance at his practice's web site reveals that he and his partners boast a host of celebrity clients, among them Jim Carrey, Kathy Ireland, Adam Sandler, Keanu Reeves, and Vin Diesel.

The filing concludes a multi-year joint investigation by the California Department of Insurance, the California Dental Board and the California Franchise Board.

The defendant's office manager and biller, Claudia Ventura, 38, is charged with 10 felony counts including insurance fraud and accessory after the fact. She will be arraigned with Kalili next week.

Bail for Kalili is recommended at $500,000. Co-defendant Ventura's bail is recommended at $25,000.

If convicted as charged, Ventura faces more than seven years in state prison. Kalili could be sentenced to more than 50 years in prison.

Dental care plan audited by California ceases operations

Community Dental Services, a managed-care dental plan with about 16,000 Medi-Cal members in Sacramento and Los Angeles counties, will cease operations and transfer its enrollees to Liberty Dental Plan on June 1, state officials announced Friday.

The move came in response to an audit by the Department of Managed Health Care, the results of which can't be released until it is finalized, said department spokeswoman Marta Bortner.

But during previous audits, the department identified problems with the way the plan approved or denied care, its grievance and appeal system and its oversight of quality of care, she said.

The plan informed the state during the audit that it would voluntarily cease operations.

"We are taking quick action to ensure that our Medi-Cal dental managed-care enrollees receive quality, timely services from our dental plans," said Toby Douglas, director of the Department of Health Care Services, which administers Medi-Cal.

That audit was prompted by a CHCF Center for Health Reporting story published in February in The Bee about Sacramento County's Medi-Cal dental managed-care program.

The story gave examples of children who had trouble obtaining treatment for painful, rotted or broken teeth, including some who endured pain for more than a year as they awaited care.

Dentist shortage leading to more emergencies

The lack of dentists and specialists in rural Californian counties is leading to high rates of tooth decay and preventable dental emergencies, especially among low-income residents.

Someone living in Eureka would have to drive 3 hours to Redding or 4 hours to Santa Rosa to get to an oral surgeon who accepts Medi-Cal.

There are no dentists in Alpine County, and the nearest dentist accepting Medi-Cal is at the Washoe Tribal Health Center in Nevada, a half-hour away. Medicare patients can go to a dentist 28 miles away in South Lake Tahoe, but that dentist stopped accepting Medi-Cal patients from the county because of the high rate of no-shows.

If they can’t get into either of those offices, patients have to make a 2.5-hour trek to Diamond Springs.

A 2006 survey conducted in four northern Californian rural counties found that this combination of low access and low incomes hurts oral health. More than 28 percent of respondents living at or below the federal poverty level hadn’t been to a dentist in five or more years. Many of them had never seen a dentist. Only 40% of respondents had been to a dentist in the previous year- the recommended length of time between visits.

This is due in large part to a lack of dentists and specialists in the area, especially those who accept Medi-Cal. For example, in the population center of McKinleyville in Humbolt County, there is one dentist for every 4,539 people.

The problem is even worse for those relying on the state’s health care program for low-income people. There’s only one dentist accepting Medi-Cal for every 71,830 county residents.

That’s well above federal standards for a dental care shortage. Counties with a ratio of one dentist for every 5,000 people are federally designated dental health professional shortage areas. But national standards recommend a target ratio of at least one dentist for every 3,000 people.

The survey found that rural counties in northern California have the highest rate of emergency room and urgent care visits for preventable dental issues than the rest of the state.

Los Angeles County record dismal for enabling poor children to get needed dental services

For many of Los Angeles County's poor children, getting in to see a dentist can be as tough as making it in Hollywood, state data show.

Last year, fewer than one in four L.A. County children with Medi-Cal dental managed care saw a dentist, one of the worst records in the state.

As a result, many children suffer for months with painful or rotted teeth before seeing a dentist or getting a referral to a specialist, dentists and children's advocates say.

"It would be like winning the jackpot if you could find a provider who is close to you and has the necessary skills and you can get an appointment in the next week or next two weeks," said Francisco Ramos-Gomez, a professor of pediatric dentistry at the UCLA School of Dentistry.

"Because these kids can't find providers and they go around in circles, their teeth get worse and worse and worse."

L.A. County is just one of two counties in the state that offers dental managed care through Medi-Cal.

In Sacramento County, dental managed care is mandatory for children. But in Los Angeles, parents have a choice. They can either sign their kids up for a dental managed care plan, or opt for the "fee-for-service" approach used in the rest of the state.

Though the majority choose fee-for-service, about 154,000 kids were enrolled in dental managed care last year in Los Angeles County.

Enjoy your morning!

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