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Senior Director of Strategic Alliances
LexisNexis Risk Solutions - Government

An old man was sitting in the waiting room for a little bit after getting his tooth pulled. The receptionist asked him if he was ok. “Yes, but I didn’t like the bad word the dentist used while he was pulling my tooth.” “What did he say?” asked the receptionist, worried. “Oops.” Da-dum-da-dum.

A study published in the Health Affair Magazine analyzed the real reason that people avoid the dentist not because they are afraid of the procedure. The top reason to avoid the dentist was the cost of the services. Seems like something that should be addressed by the Department of Health and Human Services, but until that happens, it’s a great opportunity for fraudsters, like Dr. Javad Aghaloo. Aghaloo concocted an $8 million scheme for dental procedures that were not covered by Medicare. And Aghaloo didn’t actually perform the services billed. Nor were most of these services necessary. But necessity doesn’t matter when it comes to fraud.

To recruit Medicare patients, Aghaloo falsely claimed that his dental services were covered by Medicare. He was special. And if certain procedures weren’t covered, he would do what was necessary to make them covered. For instance, tooth extractions are not covered by Medicare. No problem for Aghaloo. He would perform the tooth extraction, but charge Medicare for a bone graft procedure. Convenient that a bone graft procedure warrants a higher reimbursement by Medicare than tooth removal!

For every fraudulent procedure completed by Aghaloo , his office manager, Theresa Flores, covered for him. Between March 2016 and October 2018, Flores concealed Aghaloo’s actions by submitting more than 7,000 false claims to Medicare, totaling more than $18 million. Medicare reimbursed Aghaloo’s offices for more than $8,476,466.23.

Outstanding job by the Department of Health and Human Services. Aghaloo’s sentencing is set for January 12, 2024.

Today’s Fraud of The Day is based on article “Local dentist, ex-office manager plead guilty to Medicare fraud” published by Fox5 News.

An Imperial County dentist and his office manager admitted Tuesday in federal court to conspiring to defraud Medicare and covering it up, prosecutors said. Dr. Javad Aghaloo pleaded guilty to conspiring to commit health care fraud by billing Medicare for procedures that were not covered, not performed, or otherwise not necessary, Cindy Cipriani with the Office of the United States Attorney Southern District of California said in a news release Wednesday.

His office manager, Theresa Flores, entered a guilty plea to obstructing a Medicare audit. Aghaloo and Flores, knowing Medicare does not cover dental services, recruited Medicare patients by marketing the dental services to two individuals in Imperial County as being covered by Medicare, according to court records.

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