Benevis - Kool Smiles Dental Centers False Claims Act Complaint - Christina Bowne Relator

Case 3:16-cv-00369-JBA Document 36 Filed 09/21/15 Page 1 of 50
SEALED
UNITED STATES DISTRICT COURT
FOR THE EASTERN DISTRICT OF VIRGINIA
Norfolk Division
FILED
UNITED STATES OF AMERICA.

SEP 2 1 2015
COMMONWEALTH OF VIRGINIA,
DISTRICT OF COLUMBIA,
STATE OF GEORGIA, and
CLERK, U.S. DISTRICT COURT
NORFOLK. VA
STATE OF MARYLAND
EX REL. CHRISTINA BOWNE,
Civil Action No. 2:12cv316
Plaintiffs.
v. FIRST AMENDED COMPLAINT
KS-VAP, PC;
KOOL SMILES VAN, PC;
NCDR. L.L.C.;
CANDLER ROAD DENTAL. PC:
KOOL SMILES HOLDING CORP.: FILED UNDER SEAL
KOOL SMILES ACQUISION CORP.; PURSUANT TO
KS II HOLDINGS, INC.; 31 U.S.C. § 3730(b)2;
FRIEDMAN FLEISCHER & LOWE, LLC; VA. CODE ANN. § 8.01-216.5 B;
DR. DAVID M. VIETH, PC; D.C. CODE § 2-381.03(b)(2);
DR. DAVID M. VIETH 2, PC; O.C.G.A. § 49-4-168.2(c)(2); and
KOOL SMILES DC PC; MD. HEALTH-GEN CODE ANN.
SARA ABOLAHRARI. D.D.S.; § 2-604(a)(3)(ii).
YOLANDA ROBINSON. D.D.S.;
WYATT RUFFIN. JR., D.D.S.;
JERMEL FORD, D.D.S.;
DAVID STRANGE. D.D.S.;
KEVIN MILLER:
WILLIAM BRIGHAM;
THIEN PHAM, D.D.S.;
TUTRAN, D.D.S.:
DAVID M. VIETH, D.D.S.;
DALE G. MAYFIELD, D.M.D.:
PAUL WALKER. D.D.S.;
MARLENE NAVEDO. D.D.S.:
KENNETH LEACH; and
LISA ROHN.
DO NOT PLACE IN PRESS BOX
Defendants. DO NOT ENTER IN PACER
Comes now the Plaintiff, and for its action, states:

INTRODUCTION
1. This is an action to recover damages and civil penalties on behalf of the United
States of America, the Commonwealth of Virginia, the District of Columbia, the State of
Georgia, and the State of Maryland arising out of false claims presented by or caused to be
presented by Defendants under the joint Federal-State Medicaid program in violation of Title 31
U.S.C. §§ 3729, et seq., popularly known as the FALSE CLAIMS ACT ("FCA"); and in violation
of Va. Code Ann. §§ 8.01-216, et seq., popularly known as the Virginia Fraud Against
Taxpayers Act ("VFATA"), D.C Code §§ 2-381, et seq., popularly known as the District of
Columbia False Claims Act ("DC FCA"), O.CG.A. §§ 49-4-168, et seq., popularly known as
the Georgia False Medicaid Claims Act ("GA FMCA"), and Md. Health-Gen. Code Ann.
§§ 2-601, et seq., popularly known as the MARYLAND FALSE HEALTH CLAIMS ACT ("MD
FHCA").
2. Defendants directly and/or through conspiracy with other Defendants violated the
FCA, VFATA, DC FCA, GA FMCA, and MD FHCA bysubmitting or causing other Defendants
to submit to the Medicaid program false claims involving (1) substandard care and
inadequate/worthless services, (2) services that were not medically necessary, (3) upcoded
services, (4) services not rendered, (5) falsified statements as to the identity of the provider, and
(6) services that failed to meet the legally required quality of dental care.
3. Defendant KS-VAP, PC and/or Defendant Kool Smiles VAN, PC own and operate
a dental clinic in Portsmouth, Virginia; and they participate in the Medicaid program in the
Commonwealth of Virginia, have provided dental services to persons covered by the Medicaid
program in the Commonwealth of Virginia, and have billed or caused to be billed the Medicaid
program in the Commonwealth of Virginia for services and materials provided to persons
covered by those programs.
4. Defendant Kool Smiles DC PC owns and operates a dental clinic in Washington,
D.C. and participates in the Medicaid program in the District of Columbia, has provided dental
services to persons covered by the Medicaid program in the District of Columbia, and has billed
or caused to be billed the Medicaid program in the District of Columbia for services and
materials provided to persons covered by those programs.
5. Defendant Candler Road Dental, PC operates dental clinics and participates in the
Medicaid program in the State of Georgia, has provided dental services to persons covered by the
Medicaid program in the State of Georgia, and has billed or caused to be billed the Medicaid
program in the State of Georgia for services and materials provided to persons covered by those
programs.
6. Defendants Dr. David M. Vieth, PC and Dr. David M. Vieth 2, PC operate dental
clinics and participate and / or participated in the Medicaid program in the State of Maryland,
have provided dental services to persons covered by the Medicaid program in the State of
Maryland, and have billed or caused to be billed the Medicaid program in the State of Maryland
for services and materials provided to persons covered by those programs.
7. On or about May 11, 2012, Relator Bowne, through counsel, voluntarily provided
the information on which the allegations herein are based to the United States of America, in
compliance with 31 U.S.C. § 3730(e)(iv)(B), and on or about July27, 2015, again acting through
counsel, voluntarily provided additional information on which the allegations herein are based to
the United Statesof America, in compliance with 31 U.S.C. § 3730(e)(iv)(B)

8. On or about May 11, 2012, Relator Bowne, through counsel, voluntarily provided
the information on which the allegations herein are based to the Commonwealth of Virginia, in
compliance with Va. CODE ANN. § 8.01-216.8; and on or about July 28, 2015, Relator Bowne,
again through counsel, voluntarily provided additional information on which the allegations
herein are based to the Commonwealth of Virginia, in compliance with Va. Code Ann. § 8.01-
216.8, voluntarily provided the information on which the allegations herein are based to the
District of Columbia, in compliance with D.C. Code § 2-381.03, voluntarily provided the
information on which the allegations herein are based to the State of Georgia, in compliance with
O.CG.A. § 49-4-168.2, and voluntarily provided the information on which the allegations herein
are based to the State of Maryland, in compliance with MD. Health-Gen. Code Ann. § 2-606.
JURISDICTION AND VENUE
9. Title 31 U.S.C. § 3732(a) provides that United States District Courts shall have
jurisdiction over actions brought under the FCA. Section 3732(b) of the same title provides that
"[t]he district courts shall have jurisdiction over any action brought under the laws of any State
for the recovery of funds paid by a State or local government if the action arises from the same
transaction or occurrence as an action brought under section 3730" of the FCA. The VFATA,
DC FCA, GA FMCA, and MD FHCA counts in this action arise from the same transactions or
occurrences as the counts brought under § 3730 of the FCA.
10. Section 3732(a) of the FCA provides that: "Any action under section 3730 may be
brought in anyjudicial district in which the Defendant or, in the caseof multiple Defendants, any
one Defendant can be found, resides, transacts business, or in which any act proscribed by
section 3729 occurred." Some of the acts complained herein occurred within thisjudicial district;
and some of the Defendants transacted business in this district in furtherance of the acts
complained herein. Defendant KS-VAP, PC and Defendant Kool Smiles VAN, PC reside in this
district.
11. Under the FCA, the VFATA, the DC FCA, the GA FMCA, and the MD FHCA,
this complaint is to be filed in camera. The FCA provides for the Complaint to remain under seal
for at least sixty (60) days. The GA FMCA and MD FHCA provide for the same seal period of
sixty (60) days. Under the VFATA, the Complaint must remain under seal for at least one
hundred twenty (120) days and under the DC FCA it must remain under seal for at least one
hundred eighty (180) days. The Complaint shall not be served on the Defendants until the Court
so orders. The United States may elect to intervene and proceed with the action within sixty (60)
days after it receives both the Complaint and material evidence and information from the
Relator. The State of Georgia and State of Maryland provide for the same intervention timeline.
The Commonwealth of Virginia and the District of Columbia may make a similar election within
one hundred twenty (120) days and one hundred and eighty (180) days, respectively.
PARTIES TO THE ACTION
Defendants
12. Defendant Candler Road Dental, PC is a for-profit professional limited liability
company originally named Kool Smiles, P.C, organized and existing under the laws of the
Georgia with the purpose of rendering professional dentistry services, with its principal office at
1090 Northchase Parkway SE, Suite 150, Marietta, Georgia 30067. Defendant Dr. Tu Tran,
D.D.S. is its CEO, CFO, and Secretary. In Georgia it owns and operates eight separate dental
clinics including (1) "Forest Park" at 4458 Jonesboro Road, Forest Park, Georgia 30297; (2)
"College Park" at 5495 Old National Highway, Atlanta, Georgia 30349; (3) "Decatur" at 1756
Candler Road, Decatur, Georgia 30032; (4) "Chamblee/Buford Highway" at 4054 Buford
Highway NE, Atlanta, Georgia 30345; (5) "Lilburn" at 4030 Lawrenceville Highway, Lilburn,
Georgia 30047; (6) "Smyrna" at 2900 South Cobb Drive, Smyrna, Georgia 30080; (7) "Macon"
at 1386 Gray Highway, Macon, Georgia 31211; and (8) "Columbus" at 4519 Woodruff Road,
Unit 10, Columbus, Georgia 31904 (the "Georgia Clinics"). These clinics are branded with the
"Kool Smiles" name.
13. Defendant Candler Road Dental, PC was formed through a merger in January 2015
among entities named KS GAD, PC; Kool Smiles of Chamblee, P.C; Kool Smiles of Smyrna,
P.C; Kool Smiles GAC, P.C; Kool Smiles GAFP, P.C; Kool Smiles of Lilburn, P.C; KS
GAM, PC; and KS GASWA, PC. The surviving entity was Kool Smiles, P.C; and its name was
changed to Candler Road Dental, PC Upon information and belief, each of the Georgia Clinics
was originally owned by a separate one of the above non-surviving entities.
14. Defendant Candler Road Dental, PC through its direct and indirect subsidiaries
owns and operates at least ninety-four (94) dental practices nationwide which use the "Kool
Smiles" name and branding and almost exclusively limit their practice to infants, children, and
youths eligible for Medicaid.
15. Both KS-VAP, PC (hereinafter, "Defendant KS-VAP") and Kool Smiles VAN, PC
(hereinafter. "Defendant Kool Smiles VAN") are for-profit professional limited liability
companies organized and existing under the laws of the Commonwealth of Virginia with the
purpose of rendering professional dentistry services, and one or both of them own and operate a
dental clinic at 4072 Victory Blvd. in Portsmouth, Virginia (the "Virginia Clinic")1 which is
branded "Kool Smiles General Dentistry for Kids." Upon information and belief, they are
wholly-owned by Defendant Candler Road Dental, PC.
16. Defendant Kool Smiles DC PC is a for-profit professional limited liability
company organized and existing under the laws of the District of Columbia with the purpose of
rendering professional dentistry services, and owns and operates a dental clinic referred to by
defendants as "Hechinger" at 1531 Maryland Avenue. Washington, DC 20002 (the "D.C.
Clinic"), which is branded a "Kool Smiles" practice. Upon information and belief, Kool Smiles
DC, PC is wholly-owned by Defendant Candler Road Dental, PC.
17. Defendants Dr. David M. Vieth, PC and Dr. David M. Vieth 2, PC are for-profit
professional limited liability companies organized and existing under the laws of the Maryland
with the purpose of rendering professional dentistry services, and upon information and belief
they are wholly-owned by Defendant Candler Road Dental, PC. They own or owned and operate
or operated, individually or together, seven dental clinics in the State of Maryland, including: (1)
"Baltimore - Eastpoint" at 7839 Eastern Avenue, Baltimore, Maryland 21224; (2) "Brooklyn
Park" at 5700 Ritchie Highway, Brooklyn Park. Maryland 21225; (3) "Northeast Baltimore" at
1900 North Broadway, Baltimore. Maryland 21213; (4) "Baltimore" at 2429 Frederick Avenue,
Baltimore. Maryland 21223; (5) "Northwest Baltimore" at 4173 Patterson Avenue, Baltimore.
Maryland 21215; (6) "Takoma Park" at 1147 University Boulevard E, Takoma Park, Maryland
20912; and (7) "District Heights" at 6471 Marlboro Pike, District Heights. MD 20747 (the
"Maryland Clinics"). These clinics are branded with the "Kool Smiles" name.
1The Virginia State Medicaid website lists the Medicaid provider located at 4072 Victory Blvd. in Portsmouth, VA
as "Kool Smiles VAP. PC." No entity by that spelling appears inthe public records of Virginia, which leads Relator
18. NCDR, L.L.C. (hereinafter, "Defendant NCDR") is a for-profit limited liability
company organized under the laws of Georgia. Defendant NCDR provides management, non-
dentist staffing, and support services to Kool Smiles Companies, including the D.C. Clinic,
Georgia Clinics, the Maryland Clinics, and the Virginia Clinic (together the "Kool Smiles
Clinics"). Upon information and belief, Defendant NCDR is owned directly or indirectly by
Defendant Candler Road Dental, PC (formerly Kool Smiles, P.C) and provides services solely to
its subsidiaries.
19. Friedman Fleischer & Lowe, LLC (hereinafter, "Defendant Friedman Fleischer &
Lowe") is a for-profit business organization existing under the laws of California, with
subsidiaries existing under the laws of Delaware. Kool Smiles Holding Corp. (hereinafter,
"Defendant Kool Smiles Holding"), KS II Holdings, Inc. (hereinafter, "Defendant KS II"), and
Kool Smiles Acquisition Corp. (hereinafter. "Defendant Kool Smiles Acquisition") are for-profit
corporations organized under the laws of Delaware. All of these entities own interests in Candler
Road Dental, PC and therefore are indirect owners of the D.C. Clinic, the Georgia Clinics, the
Maryland Clinics, and the Virginia Clinic. Hereinafter, these entities are collectively referred to
as "Kool Smiles Parent Companies." The Kool Smiles Parent Companies, plus Defendant
Candler Road Dental, PC and its direct and indirect subsidiaries, are collectively referred to
herein as the "Kool Smiles Companies."
20. Defendant Sara Abolahrari, D.D.S. ("Defendant Abolahrari") is a dentist licensed
to practice in the Commonwealth of Virginia since June 19, 2007 under license number
0401411860. Defendant Abolahrari is a resident of Virginia Beach, Virginia, was a Dentist of
the Virginia Clinic, and has been employed by Defendant KS-VAP or Defendant Kool Smiles
to conclude that it is a mis-spelling of the legal name of Defendant KS-VAP.

VAN since approximately June 2007. At the time of Defendant Abolahrari's hiring as Dentist at
the Virginia Clinic, Defendant Abolahrari had one (1) year of experience practicing dentistry.
21. Defendant Wyatt "John" Ruffin, Jr., D.D.S. ("Defendant Ruffin") is a dentist
licensed to practice in the Commonwealth of Virginia since August 31, 1984 under license
number 0401006433. Defendant Ruffin participates in the Medicaid program under Medicaid
identifier 7821743 and National Provider Identification (NPI) 1033210943. Defendant Ruffin is
a resident of Roanoke, Virginia, provided dental services at the Virginia Clinic, and was
employed by Defendant KS-VAP or Defendant Kool Smiles VAN in 2007.
22. Defendant Yolanda Robinson, D.D.S. (a/k/a Yolanda Price) ("Defendant
Robinson") is a dentist licensed to practice in the Commonwealth of Virginia since October 4.
2001 under license number 0401102707. Defendant Robinson participates in the Medicaid
program under Medicaid identifier 010018851 and NPI 1760472690. Defendant Robinson is a
resident of South Hill, Virginia, provided dental services at the Virginia Clinic, and was
employed by Defendant KS-VAP or Defendant Kool Smiles VAN during the time period at
issue.
23. Defendant Jermel Ford. D.D.S. ("Defendant Ford") is a dentist licensed to practice
in the Commonwealth of Virginia since September 8, 2005 under license number 0401411161.
Defendant Ford participates in the Medicaid program under Medicaid identifier 010226945 and
NPI 1962579946. Defendant Ford was employed at Defendant KS-VAP or Defendant Kool
Smiles VAN throughout 2007 and 2008 and provided dental services at the Virginia Clinic.
24. Defendants David Strange, D.D.S.; Kevin Miller; Thien Pham, D.D.S.; Tu Tran,
D.D.S; Paul Walker, D.D.S.; David M. Vieth, D.D.S.; Dale G. Mayfield, D.M.D.; Marlene
Navedo, D.D.S; William Brigham; Lisa Rohn; and Kenneth Leach (the "Officials") are owners
and/or senior officers of one or more Kool Smiles Companies. Defendant Strange serves as the
Chief Dental Officer for one or more Kool Smiles Companies. Defendant Tran is a founding
dentist and original owner of the Kool Smiles Companies. His Virginia dentistry license number
is 0401411091 and his NPI is 1559395351. As noted above, Defendant Tran is the CEO, CFO,
and Secretary of Defendant Candler Road Dental, PC. Defendant Pham was a founding dentist
and original owner of the Kool Smiles Companies. Defendant Miller is a Director of Kool Smiles
Holding, Corp. and is responsible, along with Defendant Strange, for outreach, marketing, and
clinical oversight activities of the Kool Smiles Companies. Defendants Vieth and Mayfield serve
as the Executive Dental Officers for the Kool Smiles Companies. Defendant Vieth's NPI is
1316005804. Defendant Walker serves as the Vice President of Clinical Quality for the Kool
Smiles Companies. Defendant Navedo serves as the Regional Dental Director for the Kool
Smiles Companies in the Virginia area. Defendant Navedo's Virginia dentistry license is
0401411968. William "Bill" Brigham, though not a dentist, serves as the Vice President of one
or more of the Kool Smiles Companies and sets many of the target and production goals the
Defendant's employed dentists are required to achieve. In addition, Defendant Brigham crafts
and implements many of the corporate policies which affect the operation of Defendant KS-
VAP, Defendant Kool Smiles VAN, and the Virginia Clinic in particular. Kenneth "Ken" Leach
is a senior public relations employee of one or more of the Kool Smiles Companies who
conducts and/or organizes outreach, marketing andcomplaint response efforts for the public.
Plaintiff Relator
25. Qui tarn Plaintiff Christina Bowne is a resident of Chesapeake, Virginia, and a
former employee of NCDR who worked primarily at the Virginia Clinic, as well as trained at
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some of the Georgia Clinics and also worked at the D.C Clinic and one of the Maryland Clinics.
Relator Bowne brings this action on behalf of the United States of America, the Commonwealth
of Virginia, the District of Columbia, the State of Georgia, and the State of Maryland. Defendant
NCDR employed Relator Bowne as an office manager at the Virginia Clinic from June 2006 to
October 2009. In her employment with the Virginia Clinic, Relator Bowne scheduled patients;
assisted with dental treatments as needed; hired non-dentist staff; coordinated management of the
Virginia Clinic with corporate superiors, including Defendants Rohn, Leach, Brigham, Navedo,
Miller, Walker, and Strange; and managed the day-to-day non-clinical operations of the Virginia
Clinic. Upon hire in June 2006, Relator Bowne was sent to Georgia for training; she received
training on-site at the Georgia Clinic in Lilburn. There she practiced billing claims for the
Lilburn clinic, as well as the Columbus clinic and the Smyrna clinic, all three of which are
located in Georgia. She also traveled to the Columbus clinic and Symrna clinic locations during
this training period. In 2009, Relator Bowne was tasked with training the managers at the D.C.
Clinic and the District Heights clinic in the State of Maryland, as well as with handling
management responsibilities for these understaffed and overwhelmed clinics during that time.
Relator Bowne brings this action based on her direct, independent, and personal knowledge and
also upon information and belief.
26. Relator Bowne is an original source of information to the United States, the
Commonwealth of Virginia, the District of Columbia, the State of Georgia, and the State of
Maryland. Relator Bowne has direct and independent knowledgeof the informationon which the
allegations herein are based and has voluntarily provided the information to the United States,
the Commonwealth of Virginia, the District of Columbia, the State of Georgia, and the State of
Maryland before filing an action under the FCA, the VFATA, DC FCA, GA FMCA, and MD
FHCA.
FALSE CLAIMS ACT
27. Federal law prohibits falsely representing that work has been performed that was
not, in fact, performed, or making misrepresentations in order to obtain payment of funds to
which a party is not entitled. 31 U.S.CA. §§ 3729 et seq.
28. The False Claims Act is the primary law on which the federal government relies
to recover losses caused by fraud. Avco Corp. v. Dept. of Justice. 884 F.2d 621, 622 (D.C. Cir.
1989). The FCA creates civil liability for making a false claim for payment by the government.
Specifically:
Any person who-
(A) knowingly presents, or causes to be presented, a false or fraudulent claim for payment
or approval; [or]
(B) knowingly makes, uses, or causes to be made or used, a false record or statement
material to a false or fraudulent claim; [or]
(C) conspires to defraud the Government by getting a false or fraudulent claim allowed or
paid; [or]
(G) knowingly makes, uses, or causes to be made or used, a false record or statement
material to an obligation to pay or transmit money or property to the Government, or
knowingly conceals or knowingly and improperlyavoids or decreases an obligation
to pay or transmit money or property to the Government,
is liable to the United States Government....
31 U.S.C. § 3729(a)(1). The FCA also permits private citizens to bring qui tarn suits to enforce
the FCA. J4 § 3730(b).
29. The Supreme Court has stated that Congress intended that the FCA be broadly
applied to protect government funds and property from fraudulent claims. U.S. v. Niefert-White
Co.. 390 U.S. 228 (1968).
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30. There are at least three (3) recognized theories pursuant to which federal health
care program claims for services which are not medically necessary or fall below the standard
level of health care are legally false. These theories include:
(a) "Express Certification." An expressly false claim occurs where a provider falsely
certified compliance with a statute, regulation, or contractual term as a prerequisite to payment.
Presentation of a Medicaid claim on Health Care Financing Administration's ("HCFA") Claim
Form 1500 requires the health care provider to certify, on the claim or simultaneously with it,
that the product or services provided were "medically indicated and necessary to the health of
[the] patient." All Medicaid claims for payment are submitted on HCFA Form 1500.
Accordingly, if a provider submits a claim for reimbursement for a service that is not medically
necessary, the provider has falsely certified compliance and has therefore violated the FCA.
(b) "Implied Certification." Here, a Medicaid health care service provider is required
to sign certifications and representations of compliance with applicable law in applications to be
recognized as a participant in Medicaid, and to certify compliance in periodic reports and
statements required to remain a participant. These certifications are therefore preconditions to
eligibility to present a claim with which the provider must comply in order to be paid. Where a
provider violates the terms of participation, these certifications become false, and by legal
implication, claims filed after the violation are false.
(c) "Worthless Services." Under this theory, when a provider bills the federal
government for payment for a service which the provider knows, or should know, has no value,
such claims billed by the provider are legally false. When a service provided falls below the
customary or statutory standard of care, or has little or no value to the treatment or health of the
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beneficiary, the provider has not provided a reimbursable service and any claims made for such
services are false. See U.S. v. Villaspring Health Care Center. Inc.. 2011 WL 6337455 (E.D. Ky.
2011); see also U.S. v. NHC Health Care Corp.. 163 F. Supp. 2d 1051 (W.D. Mo. 2001).
VIRGINIA FRAUD AGAINST TAXPAYERS ACT
31. While the FCA imposes civil liability for the presentation to the federal
government of a false claim for payment, the VFATA correspondingly imposes liability for
presentation of false claims to the Commonwealth of Virginia.
32. The VFATA imposes civil liability on:
Any person who:
(a) [k]nowingly presents, or causes to be presented, a false or fraudulent claim for

payment or approval; [or]
(b) [k]nowingly makes, uses, or causes to be made or used, a false record or
statement material to a false or fraudulent claim; [or]
(c) [c]onspires to commit a violation of subdivision 1, 2, 4, 5, 6, or 7; [or]...
(7) [kjknowingly makes, uses, or causes to be made or used, a false record or
statement material to an obligation to pay or transmit money or property to the
Commonwealth or knowingly conceals or knowingly and improperly avoids or
decreases an obligation to pay or transmit money or property to the
Commonwealth;. ..
Va. Code Ann. § 8.01-216.3A. The VFATA permits private persons to bring an action
on behalf of the Commonwealth. Id. at § 8.01-216.5.
VIRGINIA'S MEDICAID DENTAL PROGRAM AND FAMIS
33. Medicaid is a jointly funded State and Federal health insurance program primarily
for eligible low-income individuals, children, parents of eligible children, pregnant women,
seniors, and people with disabilities. Medicaid was created in 1965 through Title XIX of the
Social Security Act. Dental services under the Medicaid program are an optional service for
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the adult population, individuals age 21 and older. However, dental services are a required
service for most Medicaid-eligible individuals under the age of 21, as a required component of
the Early and Periodic Screening, Diagnostic and Treatment benefit, Medicaid's child health
program.
34. FAMIS Plus is Virginia's name for children's Medicaid. Family Access to Medical
Insurance Security Plan ("FAMIS") is a joint Federal and State program that provides low-cost
health insurance for children in families that earn too much for FAMIS Plus (Medicaid) but do
not have private health insurance. Hereinafter, the FAMIS and FAMIS Plus programs in
Virginia are collectively referred to as "Medicaid," and causes of action being asserted to herein
include claims submitted under both of these programs.
35. In Virginia, the Smilesfor Children program is the name for Virginia's Medicaid
pediatric dental care program. From at least 2001 to 2008, Doral Dental USA. LLC ("Doral
Dental"), a for-profit company, served as the single dental benefits administrator under contracts
with the Commonwealth of Virginia, to coordinate all Medicaid dental services in the
Commonwealth of Virginia. In 2008, Doral Dental changed its name to DentaQuest, LLC
("DentaQuest"), and presently continues to serve as the single dental benefits administrator for
Medicaid dental services in the Commonwealth of Virginia.
36. The enabling legislation and regulations of the Medicaid program require health
care providers to ensure that they provide services only where the services "will be provided
economically and only when, and to the extent, medically necessary" and that the services "will
be of a quality which meets professionally recognized standards of health care." 42 U.S.C. §
1320c-5(a)(l); 42 C.F.R. § 1004.10(a).
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37. The federal government placed responsibility on each state to structure the
Medicaid program within statutorily specified parameters, including defining the term
"medically necessary." 42 U.S.C. § 1396a; 42 C.F.R. § 440.230(d).
38. Virginia's Medicaid dental program defines "medically necessary" to mean those
medical, dental, behavioral, rehabilitative or other health care services which:
• are reasonable and necessary to prevent illness or medical conditions, or provide early
screening, interventions, and/or treatment for conditions that cause suffering or pain,
cause physical deformity or limitation in function, cause illness or infirmity, endanger
life, or worsen a disability;
• are provided at appropriate facilities and at the appropriate levels of care for the treatment
of a member's medical conditions;
• are consistent with the diagnoses of the conditions;
• are no more intrusive or restrictive than necessary to provide a proper balance of safety,
effectiveness, efficiency and independence; and
• will assist the individual to achieve or maintain maximum functional capacity in
performing daily activities, taking into account both the functional capacity of the
individual, and those functional capacities that are appropriate for individuals of the same
age.
39. From at least 2001 to 2008, dental service providers in the Medicaid program in
Virginia were engaged via a form contract with Doral Dental, captioned "Provider Service
Agreement." A similar Provider Service Agreement now exists for contracting with DentaQuest.
This Provider Service Agreement stipulates that covered services are those services deemed
medically necessary, and the Agreement contains a representation and warranty that the provider
will "provide dental care which meets or exceeds the average standard of care for dentists
practicing in the region and will comply with all standards for dentists as established by any
State or Federal lawor regulation." The Provider Service Agreement also requires providers "to
refund payments if they are found to have [been] billed contrary to law, regulation, or [Virginia
Medicaid] policy or failed to maintain adequate documentation in support of their claims." In
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order to qualify for Virginia Medicaid, all Defendants have entered into examples of the Provider
Service Agreement containing this text.
DISTRICT OF COLUMBIA FALSE CLAIMS ACT
government of a false claim for payment, the DC FCA correspondingly imposes liability for
presentation of false claims to the District of Columbia.
41. The DC FCA imposes civil liability on:
Any person who:
(1) Knowingly presents, or causes to be presented, a false or fraudulent claim for
payment or approval;
(2) Knowingly makes, uses, or causes to be made or used, a false record or
statement material to a false or fraudulent claim; [...]
(6) Knowingly makes, uses, or causes to be made or used, a false record or
statement material to an obligation to pay or transmit money or property to the
District, or knowingly conceals or knowingly and improperly avoids or decreases
an obligation to pay or transmit money or property to the District;
(7) Conspires to commit a violation of paragraph (1), (2), (3), (4), (5), or (6) of
this subsection [...]
D.C. Code § 2-381.02(a). The DC FCA permits private persons to bring an action on
behalf of the District. Id. at § 2-381.03(b).
DISTRICT OF COLUMBIA'S DENTAL MEDICAID PROGRAM
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42. D.C. Medicaid is a joint federal-state health insurance program that provides health
care coverage to low-income and disabled adults, children, and families. To be eligible for D.C
Medicaid, an individual must be a resident of D.C. and must meet non-financial and financial
eligibility requirements. Medicaid covers many services, including dental services, at little or no
cost to the individual. The D.C Medicaid program is run by the D.C Department of Health Care
Finance. The program is called D.C Healthy Families.
GEORGIA FALSE MEDICAID CLAIMS ACT
government of a false claim for payment, the GA FMCA correspondingly imposes liability for
presentation of false claims to the State of Georgia.
44. The GA FMCA imposes civil liability on:
Any person who:
(1) Knowingly presents or causes to be presented to the Georgia Medicaid
program a false or fraudulent claim for payment or approval;
(2) Knowingly makes, uses, or causes to be made or used a false record or
statement material to a false or fraudulent claim;
(3) Conspires to commit a violation of paragraph (1), (2), (4), (5), (6), or (7) of
this subsection;
[...]
(7) Knowingly makes, uses, or causes to be made or used a false record or
statement material to an obligation to pay or transmit property or money to the

Georgia Medicaid program, or knowingly conceals or knowingly and improperly
avoids or decreases an obligation to pay or transmit property or money to the
Georgia Medicaid program [...]
O.C.G.A. § 49-4-168.1(a). The GA FMCA permits private persons to bring an action on
behalf of the State of Georgia. Id. at § 49-4-168.2 (b).
GEORGIA'S DENTAL MEDICAID PROGRAM
45. The Georgia Medicaid program is managed by the Georgia Department of
Community Health (DCH). Georgia Medicaid transitioned to a state-wide Medicaid managed
care system called Georgia Families in 2006. Nearly all Medicaid beneficiaries - including low-
income adults and children, foster care children, and pregnant women - must enroll in Georgia
Families. However, individuals with disabilities or long-term care needs do not receive services
through Georgia Families.
46. Georgia Families is a partnership between the Department of Community Health
and private care management organizations (CMOs) Amerigroup Community Care
(Amerigroup), Peach State Health Plan (Peach State), and WellCare of Georgia, Inc. (WellCare).
The three CMOs subcontract the management of their dental programs to the groups Scion
Dental of Georgia, LLC (Amerigroup), DentaQuest (Peach State), and Avesis Third Party
Administrators, Inc. (WellCare as of January 1, 2013).
47. Participating providers, including the named Defendants who directlyor indirectly
rendered dental services in the State of Georgia, are required to sign a "Provider Agreement." By
signing a Provider Agreement, the provider agrees to render only those services that are
medically necessary. In regard to medical necessity, the provider agreement from Avesis, for
19
example, states, "For purposes of the provision of services as defined in the Provider Agreement,
medical necessityshall be defined as those services appropriate and consistent with the diagnosis
of the Participating Provider and the omission of which could adversely affect the Member's
medical condition or health; compatible with the standards of acceptable medical practice in the
community; are provided in a safe, appropriate and cost-effective setting given the nature of the
diagnosis and the severity of the symptoms; and are not provided solely for the convenience of
the Member, the Participating Provider or hospital."
MARYLAND FALSE HEALTH CLAIMS ACT
government of a false claim for payment, the MD FHCA correspondingly imposes liability for
presentation of false claims to the State of Maryland.
49. The MD FHCA imposes civil liability on any person who:
(1) Knowingly present or cause to be presented a false or fraudulent claim for
payment or approval;
(2) Knowingly make, use, or cause to be made or used a false record or statement
material to a false or fraudulent claim;
(3) Conspire to commit a violation under this subtitle; [...]
(7) Knowingly make, use, or cause to be made or used, a false record or statement
material to an obligation to pay or transmit money or other property to the State
[•••]
MD. HEALTH-GEN. CODE ANN. § 2-602(a). The MD FHCA permits private persons
to bring an action on behalf of the State of Maryland. Id. at § 2-604(a).
20
MARYLAND'S DENTAL MEDICAID PROGRAM
50. The Department of Health and Mental Hygiene (DHMH) runs Maryland's
Medicaid program. HealthChoice is the State's Medicaid Managed Care Program. If an
individual qualifies for HealthChoice, they choose a Primary Care Provider (PCP) and are
enrolled with a Managed Care Organization (MCO) of their choice. If a person does not qualify
for HealthChoice (e.g., because they are also Medicare eligible, eligible for Medicaid through
spenddown, or eligible in a long-term care facility), they will still receive Medicaid services, but
through "fee-for-service" (FFS). This means that each medical provider who provides services to
the Medicaid recipient bills the Medicaid program for payment. Prior to HealthChoice and other
managed care programs, all provider claims for Medicaid services were handled this way. There
are currently eight (8) MCOs participating in HealthChoice: AMERIGROUP Community Care,
Jai Medical Systems, Kaiser Permanente, Maryland Physicians Care, MedStar Family Choice,
Priority Partners, Riverside Health of Maryland, and UnitedHealthcare.
51. The Maryland Healthy Smiles Dental Program is the Maryland Medicaid dental
program that provides coverage for children under age 21, pregnant women 21 years of age and
older, and children and adults enrolled in the Rare and Expensive Case Management (REM)
program. The Maryland Healthy Smiles Dental Program is administered by DentaQuest Service
of Maryland, LLC. "Medically necessary," as defined in DentaQuest of Maryland, LLC's Office
Reference Manual, is a service or benefit that is: (1) Directly related to diagnostic, preventative,
curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or
health condition; (2) Consistent with currently accepted standards of good medical practice; (3)
The most cost effective service that can be provided without sacrificing effectiveness or access to
care; and (4) Not primarily for the convenience of the consumer, family or provider.
21
FACTS OF CASE
52. As set forth below, Defendant KS-VAP and/or Defendant Kool Smiles VAN,
Defendant NCDR, Defendant KOOL SMILES DC PC, Defendant Candler Road Dental, PC,
Defendant Dr. David M. Vieth, PC, Defendant Dr. David M. Vieth 2, PC, and Defendant
Dentists fraudulently provided or failed to provide services involving dental fillings, stainless
steel crowns, nitrous oxide sedation, x-ray services, papoose board immobilization behavior
management, and extractions, and made claims for such services. Certain Defendants also
falsified the identity of the provider on Medicaid Claims, and all Defendants engaged in
conspiratorial conduct to submit or cause to be submitted false claims to Medicaid.
53. Except where otherwise stated, the fraudulent practices began immediately after
Defendant Kool Smiles was established in 2002. However, the fraudulent practices were further
developed and/or exacerbated when Defendant Brigham joined the practice in 2007, when Kool
Smiles ordered huge production increases in daily goals, patients treated, and "Same Day Care"
or "SDC" referrals. See \ 57, infra.
54. At all times relevant to the claims described herein, the Kool Smiles Companies
used a central billing system to submit claims to Virginia Medicaid, D.C. Medicaid, Georgia
Medicaid, Maryland Medicaid, other state Medicaid programs, and private insurers. The central
billing system was located in Atlanta, GA, and operated by employees of Defendant Kool
Smiles. As such, these employees and/or Defendant Kool Smiles actually presented the false
claims at issue.
Methodical and Consistent Overscheduling Which Resultedin Substandard Care

for All or Substantially All Patients
55. The clientele of the Virginia Clinic consists almost entirely of Medicaid
22
beneficiaries. The Virginia Clinic also limits its practice to pediatric dentistry almost
exclusively, although has expanded its programming to includeparentsof minor patients.
56. The Virginia Clinic serves approximately seventy-five (76) to one hundred three
(103) children each day. Approximately 60% of the children are under the age of five.
57. The Virginia Clinic is divided into two work sections - the Hygiene Section, used
for checkups and teeth cleaning, and the Operative Section, used for surgical and other
restorative dental work. Approximately 70% of the children begin their services in the Hygiene
Section, and each day the Virginia Clinic transfers between ten (10) to twenty (20) children from
the Hygiene Section to the Operative Section. This transfer is known as "Same Day Care" or
"SDC" Approximately 30% of the children begin their services in the Operative Section.
58. Defendant KS-VAP and/or Defendant Kool Smiles VAN advertises its practice in
part by disbursing advertising literature to children at local schools; employing community
representatives to speak with parents, other guardians, and teachers; and coordinating with
nearby Head Startprograms to treat all of their program attendees during one day.
59. Because of instructions and policies provided by Defendant Officials and Kool
Smiles Parent Companies, the Virginia Clinic provides bonuses to their dentists and staff
members based upon the monthly volume and income of the Virginia Clinic. Bonuses vary
based upon stated monthly income goals. The Virginia Clinic makes this bonus policy available
to its staff members and dentists.
Smiles Parent Companies, the Virginia Clinic maintained a schedule that allowed for twelve (12)
slots at a time to be filled for the Hygiene Section and five (5) slots at a time to be filled for the
23
Operative Section. In other words, the maximum number of patients that could be scheduled to
receive services at one time was seventeen (17). The Virginia Clinic maintained eight (8)
workstations for the Hygiene Section and five (5) workstations for the Operative Section.
61. Patients in the Operative Section were scheduled in one (1) hour blocks generally
beginning at 9:00 AM and ending at 6:00 PM Monday through Saturday. Patients in the Hygiene
Section were scheduled in forty-five (45) minute blocks generally beginning at 9:00 AM and
ending at 6:00 PM Monday through Saturday. For approximately one (1) month in July of 2008,
the Virginia Clinic decreased the standard block scheduling time for the Hygiene Section from
forty-five (45) minutes to thirty (30) minutes in order to see more patients each day.
62. During this time period, usually two (2), but never more than three (3), dentists
would be scheduled to provide services to these patients on a given day. These dentists included
Defendants Abolahrari, Ford, Robinson, and Ruffin, as well as Vinita Folck, D.D.S. and
Elizabeth Mojares, D.D.S.
63. At any one time, the Clinic could schedule seventeen (17) patients and sit thirteen
(13) patients for hygiene and operative work. These thirteen (13) patients would be treated by
two (2) or three (3) dentists and a handful of dental assistants and hygienists. This practice
resulted in patients sitting for long periods of time before they received services.
Smiles Parent Companies, the Virginia Clinic consistently and systematically pressures patients
and their parents into additional services after conducting a standard cleaning, exam, or other
hygiene service. Upon the identification of any problems or concerns with the patient's teeth or
dental hygiene, including caries (cavities), infections, plaque, calculus, or gum disease, the
24
dentist or dental assistant routinely recommends that the patient receive same-day operative
surgery to address the problem, even when there is no need to perform the operative surgery
immediately. In this manner, the Virginia Clinic increases the chance that it will continue to
receive the business of those so-identified patients.
Smiles Parent Companies, the Virginia Clinic consistently and systematically denies parents
access to their children in the exam or surgery rooms. This policy is based on the belief that
parents would object to the manner in which dental services are performed at the Virginia Clinic.
To enforce this policy, Kool Smiles Parent Companies, Defendant KS-VAP and/or Defendant
Kool Smiles VAN, and Defendant NCDR instructed their employees to prevent parents from
going into the exam or surgery rooms through various confrontational means, excuses, and, if
necessary, suggesting that the parent take their child to another facility.
66. At the Virginia Clinic, dental assistants prepare the Encounter Forms for approval
and signature by the dentists. The practice is for the dental assistant to prepare the Encounter
Form after a procedure is complete and to turn the Encounter Form over to an office assistant in
a central location in the Virginia Clinic for billing purposes. The office assistant then places the
Encounter Form in separate piles awaiting the dentists' approval and signature. The Encounter
Forms are the reports on which Medicaid claims on HCFA 1500 Forms are prepared by office
personnel at the Virginia Clinic.
67. As an office manager, the Relator personally viewed the actions of dentists and
dental assistants on a daily basis and occasionally assisted dentists in performing procedures. In
addition, she regularly communicated with upper management by email, phone, and in-person.
25
Performance ofOperative Procedures When

Worthless and/or Not Medically Necessary
68. Due to neglect, lack of supplies, or poor/improper training, many of the minor
children treated by Defendant KS-VAP, Defendant Kool Smiles VAN, Defendant KOOL
SMILES DC PC, Defendant Candler Road Dental, PC, Defendant Dr. David M. Vieth, PC, and
Defendant Dr. David M. Vieth 2, PC present with significant dental conditions, including dental
caries (cavity), infections, abscesses, plaque, calculus, broken teeth, gum disease, or
pain/sensitivity in teeth.
69. While these conditions should be addressed promptly by a dentist, the services
ordered and provided should align with the severity of the problem. Often times, a tooth may
begin to develop a caries (cavity), an area of soft decay where the enamel of the tooth has been
compromised. Depending on the extent of the decay, the tooth may be repaired with a simple
filling, in which the decay is removed and a composite sealant material is set into the tooth where
this decay used to exist. This is a common and relatively simple procedure in dentistry.
70. It was the consistent practice of Defendant KS-VAP and/or Defendant Kool Smiles
VAN; Defendant NCDR; Defendant KOOL SMILES DC PC; Defendant Candler Road Dental,
PC; Defendant Dr. David M. Vieth, PC; Defendant Dr. David M. Vieth 2, PC; and Defendant
Dentists to perform, and Kool Smiles Parent Companies to mandate, the provision of a stainless
steel crown, a more complex, invasive, and expensive intervention, instead of a filling when a
filling was medically indicated.
71. Stainless steel crowns may be medically necessary in some instances, such as
when the amount of decay on a tooth is excessive and on multiple surfaces of the tooth. A tooth
is divided into five (5) surfaces for the purposesof dental procedures- the top, front, back, inner
26
(mouth) side, and outer (lips, cheeks) side, and a varying number of cusps (points).
72. It was the consistent practice of Defendant KS-VAP and/or Defendant Kool Smiles
VAN; Defendant NCDR; Defendant KOOL SMILES DC PC; Defendant Candler Road Dental,
Dentists to perform, and Kool Smiles Parent Companies to require, the provision of a stainless
steel crown, a complex and expensive intervention, even when there was a high risk of failure of
the intervention and other services would have been medically correct.
73. Even when the provision of services at the intensity provided was indicated,
Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant KOOL SMILES DC PC;
Defendant Candler Road Dental, PC; Defendant Dr. David M. Vieth, PC; Defendant Dr. David
M. Vieth 2, PC; and Defendant Dentists consistently failed to meet reasonable standards of care.
This failure made the services provided essentially worthless, both to the patient and the
Medicaid program. For instance, Defendant Abolahrari often performed fillings when the filling
environment had been compromised. In other words, the part of a tooth that was to be filled had
become saturated with blood, saliva, or water. When any of these elements are present, the filling
is unlikely to be properly affixed and will likely fail (fall out). In addition, this type of
occurrence may result in additional decay around the tooth, ultimately doing more harm than
good for the patient.
74. Similarly, Defendant Robinson performed worthless services by ordering and
providing crowns when not medically necessary. This includes instances when Defendant
Robinson placed crowns on loose primary teeth (baby teeth) which were about to fall out on their
own. Notably, Defendant Robinson has been cited several times by the Virginia Board of
27
Dentistry, most recently regarding the provision of unnecessary crowns in 2008 and 2009.
75. Defendant Ruffin, for his part, consistently created treatment plan documents to
address dental caries (cavities) that weren't actually there. Notably, Defendant Ruffin was cited
several times by the Virginia Board of Dentistry for violations of the law.
Systematic Administration ofNitrous

Oxide Sedation Wlten Not Medically Necessary
76. Nitrous oxide is used during some dental procedures to reduce pain, lessen anxiety,
and for some behavior management purposes.
77. Certain medical "indications" must be shown by the patient for the dentist to deem
a dental service medically necessary. Indications for the use of nitrous oxide include: (1) a
fearful, anxious, or obstreperous patient; (2) certain mentally, physically, or medically
compromised patients; (3) a patient whose gag reflex interferes with dental care; (4) a patient for
whom profound local anesthesia cannot be obtained; and (5) a cooperative child undergoing a
lengthy dental procedure.
78. A "contraindication" is a specific situation in which a drug, procedure, or other
medical/dental service should not be used because it may be harmful to the patient or otherwise
inadvisable. Contraindications for the use of nitrous oxide include chronic obstructive
pulmonary disease, sickle cell anemia, severe emotional disturbances or drug-related
dependencies, first trimester of pregnancy, and treatment with bleomycin sulfate. Appropriate
fasting by the patient before sedation should also take place to avoid nausea and vomiting.
Health care providers administering any sedation must carefully evaluate and document patients
for underlying conditions that could place them at an increased risk.
79. Dental guidelines mandate that the use of sedation for children age twelve and
28
under be avoided except in extraordinary situations due to the risks of unobserved respiratory
obstruction and the possibility that children may reach unintended higher levels of sedation
despite the intended level of minimal sedation. Defendants systematically ignored this guideline.
80. Medicaid covers the expense and service costs of nitrous oxide, and the
administration of nitrous oxide is reported using the American Dental Association's code of
dental procedures and nomenclature, Current Dental Terminology ("CDT") as CDT Code
D9230. The Medicaid reimbursement for this CDT code item is approximately thirty (30)
dollars per claim, depending on the state Medicaid program and the year in which the service
was rendered.
81. Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant NCDR; and
upon information and belief Defendants Kool Smiles DC PC; Defendant Candler Road Dental,
Dentists, in accordance with quotas and policies set by Kool Smiles Parent Companies,
performed nitrous oxide sedation on nearly every patient on nearly every visit. Under Medicaid
reimbursement rules, only one (1) unit (fifteen (15) minutes) may be paid for Medicaid, although
these defendants routinely provided up to forty-five (45) minutes of sedation (the longest
medically allowable amount) due to extensive patient backlog resulting from overscheduling.
Nevertheless, even if these defendants provided mere seconds of nitrous oxide to a patient, this
procedure was still billed as if an entire unit had been provided.
82. As the Kool Smiles Clinics so regularly bill for nitrous oxide services, their
respective Encounter Forms have a section for nitrous oxide administration that allows for
simple marks indicating whether or not nitrous oxide was administered.
29
83. Defendant KS-VAP and/or Defendant Kool Smiles VAN; and upon information
and belief Defendants NCDR, Kool Smiles DC PC, Candler Road Dental, PC, Dr. David M.
Vieth, PC, Dr. David M. Vieth 2, PC and Defendant Dentists systematically defrauded the
United States, the Commonwealth of Virginia, the District of Columbia, the State of Georgia,
and the State of Maryland by administering nitrous oxide sedation to all patients except pregnant
women and persons forcibly declining to receive it, regardless of the presence or absence of
indications for sedation. The majority of nitrous oxide administrations by the Kool Smiles
Clinics are not medically necessary, and the claims by the Kool Smiles Clinics associated with
such services are false. In regard to the Virginia Clinics the basis for this allegation is the
Relator's seeing nitrous oxide sedation being administered to all patients she observed except
pregnant women, and persons forcibly declining to receive it regardless of the presence or
absence of indications for sedation, and her knowledge that the majority of services provided by
the Kool Smiles Clinics are billed to Medicaid programs. The basis for this belief is Relator's
observation that the Defendants provided the same treatments outside her presence as they did in
her presence. In regard to the other clinics the basis of this allegation is the Relator's knowledge
that the Kool Smiles Companies impose nation-wide discipline in regard to their billing
practices, and her seeing bills in the DC, Maryland and Georgia Clinics in which she observed
high rates of billings for nitrous oxide (CDT D9230).
Systematic Administration ofNitrous Oxide Sedation

by Non-Qualified Individuals
84. Application of nitrous oxide for a dental procedure must be performed by a
qualified dentist who has met the educational requirements appropriate for the level of sedation
applied to the patient. Regulations enacted under Va. Code Ann. § 54.1-2400 expressly prohibit
any person other than a dentist or a dental hygienist from administering nitrous oxide. 18 VAC §
30
60-20-120.
85. The level of sedation intended through the use of nitrous oxide in dental
procedures is minimal sedation, or conscious sedation. A patient under minimal sedation should
be fully conscious and able to maintain verbal communication and respond appropriately to
physical stimulation throughout the procedure. Excessive sleep or unconsciousness can signal
respiratory depression, a potentially life-threatening reaction to nitrous oxide that requires
immediate first-aid treatment and monitoring.
86. At the Virginia Clinic, dental assistants, rather than dentists, routinely administer
nitrous oxide sedation. The Virginia Clinic's dental assistants have neither received any formal
education and/or training in the administration of inhalation analgesia, nor obtained certification
in basic life support for health care providers. Moreover, a dentist is not usually present during
the induction of the sedation at the Virginia Clinic. Such administration in the absence of the
dentist violates express dental healthcare regulations of the Commonwealth of Virginia and other
applicable standards of care.
87. Patients frequently remain under sedation for forty-five (45) due to the prolonged
wait from sitting to the provision of actual services.
88. On information and belief, Defendant KS-VAP and/or Defendant Kool Smiles
VAN and Defendant Dentists systematically defrauded the United States and the Commonwealth
of Virginia by administering nitrous oxide sedation through Virginia Clinic employees not
legally qualified to perform such services, and otherwise in such a manner that was unsafe and
endangered the lives and health of the patients, and by failing to comply with the terms of
Medicaid participation and by submitting Medicaid claims for these services. The source of this
31
information is the Relator's seeing nitrous oxide sedation systematically being administered in
such manner, and her knowledge that the majority of services provided by the VirginiaClinic are
billed to Medicaid. The basis for this belief is Relator's observation that the Defendants
employed the same practices outside her presence as they did in her presence.
Behavior Management in Pediatric Dentistry and Kool Smiles'

Systematic Use ofPapoose Boards When Not Medically Necessary
89. Most pediatric dental patients can be managed effectively using basic
communicative techniques such as tell-show-do, voice control, positive reinforcement, and
distraction. The payment for basic behavior management services is included in the fee for
primary dental services. DEPARTMENT OF HEALTH & HUMAN SERVICES, GUIDE TO CHILDREN'S
DENTAL Care IN MEDICAID app. A. at 19. The Department of Health and Human Services
estimates that 85% of children are generally cooperative in dental treatment and do not need
behavior management service beyond these basic communication techniques. Id. at 6.
90. Services that require a dentist to spend substantially more time than normal
because of a child's inability to cooperate are covered services and may be billed as "behavior
management, by report." Hereinafter, these behavior management services which extend beyond
basic communication techniques are referred to as "advanced behavior management" services.
91. Medicaid covers the expense and service costs of advanced behavior management
services. The CDT code for advanced behavior management services is D9920, and the
Medicaid reimbursement is approximately sixty (60) dollars, depending on the Medicaid
program and the year in which the service was rendered. Providers must document the exhibited
behavior that requires the use of behavior management techniques and the advanced behavior
management techniques employed.
32
92. A papoose board is a behavior management device used to restrain a child. The
papoose board works by placing the patient on a flat board and wrapping the patient with wide
fabric straps that restrain the child's upper body, middle body, wrists, arms, and legs, rendering
the child immobile and unable to move his or her extremities.
93. Established standards for pediatric dental care provide for immobilization
techniques only where the patient is unwilling or unable to control movements and presents a
danger to staff or self during treatment procedures deemed necessary. Parental consent is also
required for use of the papoose board.
94. Employees of Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant
NCDR; Defendant KOOL SMILES DC PC; Defendant Candler Road Dental, PC; Defendant Dr.
David M. Vieth, PC; and Defendant Dr. David M. Vieth 2, PC prepared a papoose board for use
for all or substantially all children under eight (8) years of age based on instructions from Kool
Smiles Parent Companies and Defendant Officials. When a papoose board was used, Defendant
Dentists and/or employees of Defendants systematically told parents that their children were
misbehaving or uncooperative and needed immobilization, and in many cases this was untrue.
Relator personally observed that most of the children that the dentists ordered restrained were
cooperative and well-behaved. However, in most cases, the parents, who were denied access to
their children in the exam rooms, relied on the dentists' representations of necessity, which in
many cases were false, in consenting to their children's restraint on papoose boards.
95. On information and belief, the Kool Smiles Clinics' use of the papoose board
traumatizes many of the children placed on it. The source of this information is the Relator's
personal observation of children restrained in procedures she participated in, many of whom
33
sweated through their clothing or otherwise exhibited trauma symptoms due to the effects of the
restraints placed upon them. Defendant KS-VAP and/or Defendant Kool Smiles VAN even
purchased hair dryers and a clothes dryer so that employees could attempt to clean the children
as much as possible before sending them back to their parents, so that the parents would not find
out that the children had been so traumatized.
96. On information and belief, the Kool Smiles Clinics' use of the papoose board is
not medically necessary for a majority of the children on whom it used. The source of this
information is the Relator's personal observation of children whose behavior did not signal that
restraint was necessary and yet were, at the direction of the relevant dentist, still restrained.
Relator observed that approximately thirty five percent (35%) of all patients seen at the Virginia
Clinic were restrained with a papoose board.
97. Additionally, for many children who were treated at the Kool Smiles Clinics, the
Defendants would only restrain the child's wrists in anticipation of the child possibly raising his
or her hands during the procedures undertaken that day, even if there was no proof or indication
that the child would act in such a manner. Despite only restraining the child's wrists on these
occasions, the Defendants billed Medicaid programs for the full service of the papoose board.
98. In one instance. Relator contacted Defendant Kool Smiles' billing department for
clarification regarding this issue. Employees of Defendant Kool Smiles told relator that
whenever the papoose board was used, even if only a single part or restraint (wrists, legs, etc.)
was used, Kool Smiles Companies would still bill Medicaid programs for the entire papoose
board fee.
Performing the Maximum Number ofStainless Steel Crown

Implants WhileAvoiding Medicaid Scrutiny
34
99. To investigate abuse or misuse of funds by Medicaid providers, the Medicaid
program and associated contractors have systems in place that may alert when a provider has
exceeded a threshold in billing. These "flags" were known to the Kool Smiles Companies and
exploited. One such "flag" involved the provision of more than six (6) crowns.
100. Knowing that billing for more than six (6) crowns for one patient in one day would
raise concerns from Medicaid, Defendant Officials and Kool Smiles Parent Companies instructed
Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant KOOL SMILES DC PC;
Defendant Candler Road Dental, PC; Defendant David M. Vieth, PC; Defendant David M. Vieth
2, PC; and Defendant Dentists to habitually perform five (5) or six (6) crown implants,
regardless if such procedures were medically necessary. In this manner, Defendant KS-VAP
and/or Defendant Kool Smiles VAN; Defendant KOOL SMILES DC PC; Defendant Candler
Road Dental, PC; Defendant David M. Vieth, PC; and Defendant David M. Vieth 2, PC were
able to maximize profits while minimizing the risk of detection, regardless of the harm such
actions caused to patients and the Medicaid programs.
101. For instance, Relator personally observed Defendant Robinson on a multitude of
occasions performing up to six (6) crown implant procedures, despite the fact that such
procedures were not medically necessary or reasonable.
102. On information and belief, Defendant KS-VAP and/or Defendant Kool Smiles
VAN; Defendant KOOL SMILES DC PC; Defendant Candler Road Dental, PC; Defendant
David M. Vieth, PC; and Defendant David M. Vieth 2, PC systematically performed and billed
Medicaid for these procedures. The source of this information is Relator's personal observation
of children undergoing such procedures by Defendant Dentists and Relator's knowledge that the
35
majority of services provided are billed to Medicaid. The basis for this belief is Relator's
observation that Defendant Dentists performed the same types of operations outside Relator's
presence as they did in her presence.
Systematic Upcoding of Coronal Remnants Extraction Services
103. Basic tooth extractions are referred to as "routine extractions" and are billed as
CDT Code D7140. When a permanent tooth is ready to replace a primary tooth, the primary
tooth begins to dissolve, forming a hollow shell, and loosen from the gums as the permanent
tooth presses upon it. When the permanent tooth does not properly exfoliate the hollow shell of
the primary tooth, a "coronal remnant extraction" may be needed. This is billed under CDT Code
D7111. While both procedures consist of similar tasks, routine extractions merit more in
reimbursement. For example, in the State of Maryland, a coronal remnant extraction represented
by CDT Code D7111 is reimbursed at twenty-seven (27) dollars, while a "routine extraction"
represented by CDT Code D7140 is reimbursed at approximately one hundred and three (103)
dollars; the difference in reimbursement being approximately seventy-six (76) dollars.
104. Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant NCDR;
Defendant KOOL SMILES DC PC; Defendant Candler Road Dental, PC; Defendant Dr. David
M. Vieth, PC; Defendant Dr. David M. Vieth 2, PC; and Defendant Dentists would
systematically bill the extraction of coronal remnants as a routine extraction, despite the fact that
the extraction only removed a loose, hollow shell from the gum line with no root affixing the
tooth to the jaw instead of removing an actual tooth.
105. The source of this information is the Relator's personal observation that in many
cases of billing for routine extraction services, the "extracted" tooth was in fact a coronal
remnant which had simply not been completely exfoliated by the underlying permanent tooth.
36
In addition, x-rays of the subject patients demonstrate that only a hollow shell of a primary tooth
was in place to be extracted.
Performance ofX-Rays When Not Medically Necessary
106. X-rays are used by dentists and dental hygienists to assess enamel and bone in a
patient's mouth and check for cavities and other dental problems. X-rays will generally, but not
always, be necessary for new patients in order to establish a baseline reading.
107. Regardless of whether patients were new or established and regardless of whether
it was medically necessary to do so, Defendant KS-VAP and/or Defendant Kool Smiles VAN;
Defendant KOOL SMILES DC PC; Defendant Candler Road Dental, PC; Defendant Dr. David
M. Vieth, PC; Defendant Dr. David M. Vieth 2, PC; and Defendant Dentists systematically
ordered x-rays on all or substantially all patients. As a result, children were exposed to
unnecessary x-rays and associated ionizing radiation, without any benefit to the patient or the
patient's dental health.
108. While x-rays are not dangerous in low doses, studies have shown a link between
certain types of cancer and x-rays.
Smiles Parent Companies, Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant
KOOL SMILES DC PC; Defendant Candler Road Dental, PC; Defendant Dr. David M. Vieth,
PC; Defendant Dr. David M. Vieth 2, PC; and Defendant Dentists performed these unnecessary
services on virtually every child. Moreover, Defendant Kool Smiles' standard operating
procedure manual mandates that x-rays be performed on each patient whenever that patient
becomes eligible for a covered x-ray under their insurance plan, regardless of the medical
necessity of such procedure.
37
Billingfor Non-Diagnostic X-rays
110. The Medicaid programs cover diagnostic x-ray services. X-rays are pictures of the
teeth, bones, and / or surrounding soft tissues used to diagnose, screen for, and help identify
problems with the teeth, mouth, and jaw.
111. In many instances, the x-rays taken at the Kool Smiles Clinics were non-diagnostic
because they were blurry, images were overlapping, or the x-ray was otherwise impaired. Such
x-rays were not diagnostic because they were useless for evaluation and treatment purposes. The
Defendants did not re-take the x-rays either. Defendant KS-VAP and/or Defendant Kool Smiles
VAN; Defendant KOOL SMILES DC PC; Defendant Candler Road Dental, PC; Defendant Dr.
David M. Vieth, PC; and Defendant Dr. David M. Vieth 2, PC billed for such x-ray services.
Evaluation and treatment decisions were therefore often made without effective x-rays, even
where they would have been medically necessary and reasonable to develop accurate treatment
plans that would maximize the benefit to the patient and minimize the costs to the Medicaid
programs.
112. The source of this information is Relator's personal observation of non-diagnostic
x-rays and Relator's knowledge that the majority of defendants' x-ray services are billed to
Medicaid. The basis for this belief is Relator's observation that Defendants performed the same
types of x-rays outside Relator's presence as they did in her presence.
Failure to Secure Informed Consentfor Foster Children
113. Many children receiving Virginia Medicaid services are wards of the
Commonwealth of Virginia. As such, while the children may live in foster homes, the
Commonwealth of Virginia is the sole legal custodian of these children. Notably, the Virginia
38
Clinic treats a large number of foster children.
114. When these patients see a health care provider, such as a dentist, for services
greater than a routine check-up or cleaning, the provider is legally required to secure the
informed consent of the Department of Social Services office with authority over that individual
before performing such services. In the practice of dentistry, the dividing line between needing to
seek parental consent and proceeding without parental consent is when any numbing agent or
procedure is involved. For instance, if the dentist believes the child should receive a crown, and
ancillary to that crown receive novacaine or another numbing agent, the dentist is legally
required to have the consent of a parent or legal guardian before applying the analgesic.
115. Upon information and belief, Defendant KS-VAP and/or Defendant Kool Smiles
VAN and Defendant NCDR systematically treated foster children without informed consent for
the provision of the relevant services. This was not merely the result of ignorance or simple
error. Instead, senior management at Kool Smiles Parent Companies were informed directly by
Relator and other parties that securing such informed consent was required under the law and
that Defendants KS-VAP and NCDR had systematically failed to abide by this law. Specifically,
Relator told Defendant Brigham that foster children could not be seen under the "SDC" program.
Instead of addressing this issue, Defendant Brigham simply turned and walked away.
116. Failure to seek and obtain informed consent makes a claim false because the
underlying service lacks medical necessity and fails to meet the standard of care.
Failure to Meet the Standard ofCare and Other Legal Requirements
117. Medicaid reimbursement rules mandate that a provider meet all legal requirements,
the recognized standard of care and medical necessity questions before a claim for payment may
be approved. If a provider presents a claim for payment knowing that these requirements have
39
not been met, this claim is false for purposes of the FCA.
118. Defendant KS-VAP and/or Defendant Kool Smiles VAN routinely submitted
claims for payment they knew or should have known did not meet the requirements for Medicaid
payment.
119. In one instance, Defendant Ford allowed, and in fact, instructed, dental assistants
employed by Defendant NCDR at the Virginia Clinic to perform dental fillings on patients,
despite the fact that only dentists have the requisite training, education, and licensure to perform
such a service. Dental hygienists and dental assistants are authorized neither to bill for such
services nor perform such services in the first place. Defendant Ford was specifically
reprimanded for this violation by the Virginia Board of Dentistry.
120. The source of this information is Relator's discussions with Defendant Ford's
hygienist who informed Relator that the services had been performed in such a manner. This
discussion is corroborated by the report and reprimand by the Virginia Board of Dentistry which
covered the same occurrences over the same time period.
Falsifying the Identity ofthe Individual Provider - Background
121. Federal law requires states to keep a list of certified providers participating in
federal health care programs, such as Medicaid. 42 U.S.C. § 1396a(a)(59).
122. Before a Virginia dentist may perform services which are billable to Medicaid, the
dentist must become a provider by applying and receiving certification and entering into a
Provider Service Agreement with Doral Dental/DentaQuest, the Medicaid dental administrator
for Virginia. The dentist must submit proof of licensing and insurance, and agree to terms of the
Provider Service Agreement. Doral Dental/DentaQuest reviews the application and returns a
40
response to the provider in approximately ninety (90) days. Until the dentist has received the
certification response from Doral Dental/DentaQuest, the Virginia Clinic cannot make valid
claims to Medicaid for services performed by the dentist.
123. At Kool Smiles, corporate policy provides that each newly-hired dentist will
receive between one (1) and three (3) days' training. This training is provided by one of the
senior dentists, such as Defendants Tran, Navedo, Walker, or Strange, and involves an on-site
visit by the senior dentist.
Falsifying Identity ofProvider- Services by Dr. Abolahrari
124. Defendant Abolahrari began working for the Virginia Clinic in mid-2007.
Defendant Abolahrari provided dental services to patients since the beginning of her employment
at the Virginia Clinic under the training and supervision of the above-mentioned senior dentists.
As the supervising dentists directed, the services performed during this time were billed under
the senior dentists' names and NPIs.
125. While Defendant Abolahrari performed such services allegedly under the
supervision of the senior dentists, such dentists were not consistently present with Defendant
Abolahrari when she performed various procedures. Frequently the senior dentists were on
conference calls, at lunch, or occupied with other tasks. Nevertheless, the services provided by
Defendant Abolahrari were billed as if performed by the senior dentists. Specifically, each senior
dentist directed employees of Defendant NCDR to bill the services as if that senior dentist had
performed the services themselves.
126. Upon information and belief, this direction caused Defendant KS-VAP and/or
Defendant Kool Smiles VAN to submit claims with the senior dentists named as the dentist
41
providing the service when in fact Defendant Abolahrari was the providing dentist.
127. These claims therefore fail to meet the requisite standards in two ways: first, the
identity of the providing dentist was falsified; second, had Defendant KS-VAP and/or Defendant
Kool Smiles VAN properly billed these services, they would also not be reimbursable as
Defendant Abolahrari was not yet certified to provide care for Medicaid patients and receive
Medicaid reimburse billed under her name and NPI.
128. On information and belief, Defendants NCDR, KS-VAP and/or Kool Smiles
systematically billed for the services of trainee dentists as if the services had been provided by
Defendants Tran, Navedo, Walker, or Strange.
Falsifying Identity ofProvider- Services by Dr. Ruffin
129. Defendant Ruffin began working for the Virginia Clinic in June 2007. Defendant
Ruffin provided dental services to patients since the beginning of his employment at the Virginia
Clinic under the training and supervision of the above-mentioned senior dentists. As the
supervising dentists directed, the services performed during this time were billed under the senior
dentists' names and NPIs.
130. While Defendant Ruffin performed such services allegedly under the supervision
of the senior dentists, such dentists were not consistently present with Defendant Ruffin when he
performed various procedures. Frequently the senior dentists were on conference calls, at lunch,
or occupied with other tasks. Nevertheless, the services provided by Defendant Ruffin were
billed as if performed by the senior dentists. Specifically, each senior dentist directed employees
of Defendant NCDR to bill the services as if that senior dentist had performed the services
themselves.
42
providing the service when in fact Defendant Ruffin was the providing dentist.
Falsifying Identity ofProvider —Services by Dr. Robinson
132. Defendant Robinson began working for the Virginia Clinic in early 2007.
Defendant Robinson provided dental services to patients since the beginning of her employment
at the Virginia Clinic under the training and supervision of the above-mentioned senior dentists.
As the supervising dentists directed, the services performed during this time were billed under
the senior dentists' names and NPIs.
133. While Defendant Robinson performed such services allegedly under the
supervision of the senior dentists, such dentists were not consistently present with Defendant
Robinson when she performed various procedures. Frequently the senior dentists were on
conference calls, at lunch, or occupied with other tasks. Nevertheless, the services provided by
Defendant Robinson were billed as if performed by the senior dentists. Specifically, each senior
dentist directed employees of Defendant NCDR to bill the services as if that senior dentist had
performed the services themselves.
providing the service when in fact Defendant Robinson was the providing dentist.
KoolSmiles Parent Companies' Establishment, Enforcement, and Condoning

ofPolicies Which Result In Fraudulent Claims and Knowledge ofLegal Violations
135. Kool Smiles Parent Companies assist with the recruiting, hiring, and training of all
dentists employed by Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant
43
KOOL SMILES DC PC; Defendant Candler Road Dental, PC; Defendant Dr. David M. Vieth,
PC; and Dr. David M. Vieth 2, PC. Kool Smiles Parent Companies also issue and institute
policies and procedures which the Kool Smiles Clinics follow and direct the Kool Smiles
Clinics' compensation of their dentists.
136. One such policy instituted by Kool Smiles Parent Companies is a bonus incentive
for an increased volume of patients and/or procedures.
137. Other policies instituted by Kool Smiles Parent Companies also relate to
production goals; however, these mandate that each clinic, such as the Virginia Clinic, and each
dentist achieve previously established daily or monthly quotas. Specifically, if a dentist fails to
provide a specified number of stainless steel crowns (or other identified procedure) in a given
time period, that dentist may be subject to a corrective action plan. If the dentist continues to fail
to meet this quota, their employment may be terminated. The Relator observed, and it was
corroborated by documentary evidence and statements by other parties, that the quotas set by
Defendant Officials and Kool Smiles Parent Companies were impossible to achieve without
performing medically unnecessary crowns and providing services in a hasty and substandard
manner.
138. In addition to this policy, each clinic was required to meet a minimum number of
"SDC" treatments each day, in which the dentist, dental assistant, or other staff member would
pressure a parent to allow their child to receive additional operative procedures after they
claimed to have identified problems during routine hygiene work. Failure to meet this quota
would result in the clinic's reprimand by Defendant Officials.
139. Every quarter, Defendants Brigham, Strange, Vieth, Walker, Miller, and Mayfield,
44
among others, would hold "dash" meetings, in which they would set the quotas that dentists at
Kool Smiles Companies were expected to meet and discuss other policies to increase production
at the Kool Smiles Clinics.
140. Kool Smiles Companies and Defendant Officials knew of and enforced the policies
described herein solely for financial gain and without regard to medical necessity. In one
instance, the Relator overheard Defendant Brigham state, "I don't care. I have a yacht payment
to make" when questioned by Angela Austin, D.D.S. about the production quotas he and the
other senior management had set.
DEFENDANTS' VIOLATIONS OF THE FALSE CLAIMS ACT, THE VIRGINIA

FRAUD AGAINST TAXPAYERS ACT, THE DISTRICT OF COLUMBIA FALSE
CLAIMS ACT, THE GEORGIA FALSE MEDICAID CLAIMS ACT, AND THE
MARYLAND FALSE HEALTH CLAIMS ACT
Summary of Violations
141. Papoose Boards Not Medically Necessary: By carrying out a policy of restraining
children with papoose boards, regardless of medical indications for the use of such restraints,
Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant Kool Smiles DC PC;
Defendant Candler Road Dental, PC; Defendant David M. Vieth, PC; and Defendant David M.
Vieth 2, PC defrauded the United States, the Commonwealth of Virginia, the District of
Columbia, the State of Georgia, and the State of Maryland by knowingly presenting, and the
Defendant Dentists defrauded the United States, the Commonwealth of Virginia, the District of
Columbia, the State of Georgia, and the State of Maryland by knowingly causing the Kool
Smiles Clinics to present, false claims to the Virginia, D.C, Georgia, and Maryland Medicaid
programs for payment of behavioral management services which were not medically necessary.
These claims were false because the lack of medical necessity for the services made the express
45
certification of medical necessity in the HCFA 1500 form, on which the claims were submitted,
false. Additionally, Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant Kool
Smiles DC PC; Defendant Candler Road Dental, PC; Defendant David M. Vieth, PC; and
Defendant David M. Vieth 2, PC defrauded the United States, the Commonwealth of Virginia,
the District of Columbia, the State of Georgia, and the State of Maryland, by making, and the
Columbia, the State of Georgia, and the State of Maryland by causing Defendant KS-VAP and/or
Defendant Kool Smiles VAN; Defendant Kool Smiles DC PC; Defendant Candler Road Dental,
PC; Defendant David M. Vieth, PC; and Defendant David M. Vieth 2, PC to make, false
statements of the medical necessity of such services in the HCFA 1500 forms for the resulting
claims.
142. Papoose Boards Used Without Valid Parental Consent: By obtaining informed
parental consent for use of papoose boards through false representations, Defendant KS-VAP
and/or Defendant Kool Smiles VAN; Defendant Kool Smiles DC PC; Defendant Candler Road
Dental, PC; Defendant David M. Vieth, PC; and Defendant David M. Vieth 2, PC defrauded the
and the State of Maryland by knowingly presenting, and the Defendant Dentists defrauded the
and the State of Maryland by knowingly causing the Kool Smiles Clinics to present, false claims
to the Virginia, D.C, Georgia, and Maryland Medicaid programs for payment of behavioral
management services which did not meet the standard of care. These claims were false because
a lack of valid informed consent rendered the care provided substandard, which violated the
Provider Service Agreements and made the certifications on the HCFA 1500 form, on which the
46
claims were submitted, false. The parental consents were invalid because they were obtained by
false representations. Additionally, Defendant KS-VAP and/or Defendant Kool Smiles VAN;
Defendant Kool Smiles DC PC; Defendant Candler Road Dental, PC; Defendant David M.
Vieth, PC; and Defendant David M. Vieth 2, PC defrauded the United States, the
Maryland by making, and the Defendant Dentists defrauded the United States, the
Maryland by causing Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant Kool
Defendant David M. Vieth 2, PC to make false statements of compliance with all laws in the
HCFA 1500 forms for the resulting claims.
143. Papoose Board Services Not Rendered: By billing for the use of a papoose board
when a papoose board was only used for the child to lay on and not to restrain anything but the
wrists of the child, Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant KOOL
SMILES DC PC; Defendant Candler Road Dental, PC; Defendant David M. Vieth, PC; and
Defendant David M. Vieth 2, PC defrauded the United States, the Commonwealth of Virginia,
the District of Columbia, the State of Georgia, and the State of Maryland by knowingly
presenting, and the Defendant Dentists defrauded the United States, the Commonwealth of
Virginia, the District of Columbia, the State of Georgia, and the State of Maryland by knowingly
causing the Kool Smiles Clinics to present, false claims to the Virginia, D.C, Georgia, and
Maryland Medicaid programs for payment of behavioral management services which were not
rendered. These claims were false because the services claimed as billed were not rendered,
which made the HCFA 1500 form, on which the claims were submitted, false. Additionally,
47
Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant Kool Smiles DC PC;
Defendant Candler Road Dental, PC; Defendant David M. Vieth, PC; and Defendant David M.
Vieth 2, PC defrauded the United States, the Commonwealth of Virginia, the District of
Columbia, the State of Georgia, and the State of Maryland by making, and the Defendant
Dentists defrauded the United States, the Commonwealth of Virginia, the District of Columbia,
the State of Georgia, and the State of Maryland by causing Defendant KS-VAP and/or Defendant
Kool Smiles VAN; Defendant Kool Smiles DC PC; Defendant Candler Road Dental, PC;
Defendant David M. Vieth, PC; and Defendant David M. Vieth 2, PC to make false statements
that services were rendered as billed in the HCFA 1500 forms for the resulting claims.
144. Nitrous Oxide Sedation Not Medically Necessary: By carrying out a policy of
administering nitrous oxide to almost every patient, regardless of medical indications for
sedation, Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant Kool Smiles DC
PC; Defendant Candler Road Dental, PC; Defendant David M. Vieth, PC; and Defendant David
M. Vieth 2, PC defrauded the United States, the Commonwealth of Virginia, the District of
Columbia, the State of Georgia, and the State of Maryland by knowingly presenting, and the
Columbia, the State of Georgia, and the State of Maryland by knowingly causing the Kool
Smiles Clinics to present false claims to the Virginia, D.C, Georgia, and Maryland Medicaid
programs for payment of sedation services which were not medically necessary. These claims
were false because the lackof medical necessity for the services made the express certification of
medical necessity in the HCFA 1500 form, on which the claims were submitted, to be false.
Additionally, Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant Kool Smiles
DC PC; Defendant Candler Road Dental, PC; Defendant David M. Vieth, PC; and Defendant
48
David M. Vieth 2, PC defrauded the United States, the Commonwealth of Virginia, the District
of Columbia, the State of Georgia, and the State of Maryland by making, and the Defendant
Dentists defrauded the United States by causing Defendant KS-VAP and/or Defendant Kool
Smiles VAN; Defendant Kool Smiles DC PC; Defendant Candler Road Dental, PC; Defendant
David M. Vieth, PC; and Defendant David M. Vieth 2, PC to make false statements of the
medical necessity of such services in the HCFA 1500 forms for the resulting claims.
145. Nitrous Oxide Sedation Administered by Non-Qualified Individuals: By
subjecting pediatric and other patients to sedation services that were administered by dental
assistants without close supervision, Defendant KS-VAP and/or Defendant Kool Smiles VAN;
Defendant Kool Smiles DC PC; Defendant Candler Road Dental, PC; Defendant David M.
Vieth, PC; and Defendant David M. Vieth 2, PC provided unsafe dental services to such patients,
and defrauded the United States, the Commonwealth of Virginia, the District of Columbia, the
State of Georgia, and the State of Maryland by knowingly presenting, and the Defendant Dentists
defrauded the United States, the Commonwealth of Virginia, the District of Columbia, the State
of Georgia, and the State of Maryland by knowingly causing Defendant KS-VAP and/or
Defendant Kool Smiles VAN; Defendant Kool Smiles DC PC; Defendant Candler Road Dental,
PC; Defendant David M. Vieth, PC; and Defendant David M. Vieth 2, PC to present, false
claims to Medicaid for payment of these services. The claims were false because Defendants
had certified in the respective Medicaid Provider Service Agreements to meet or exceed an
average standard of care in the provision of dental services and failing to meet this condition
rendered claims filed after the violation of participation false.
146. Stainless Steel Crowns Not Medically Necessary: By carrying out a policy to
provide stainless steel crowns to almost every patient, regardless of the medical necessity of such
49
services and when simple, less expensive filings were both more medically appropriate and less
invasive to the minor patients involved, Defendant KS-VAP and/or Defendant Kool Smiles
VAN; Defendant Kool Smiles DC PC; Defendant Candler Road Dental, PC; Defendant David
M. Vieth, PC; and Defendant David M. Vieth 2, PC defrauded the United States, the
Maryland by knowingly presenting, and the Defendant Dentists defrauded the United States, the
Maryland by knowingly causing the Kool Smiles Clinics to present, false claims to the Virginia,
D.C, Georgia, and Maryland Medicaid programs for payment of such operative services which
were not medically necessary. These claims were false because the lack of medical necessity for
the services made the express certification of medical necessity in the HCFA 1500 form, on
which the claims were submitted, false. Additionally, Defendant KS-VAP and/or Defendant
Kool Smiles VAN; Defendant Kool Smiles DC PC; Defendant Candler Road Dental, PC;
Defendant David M. Vieth, PC; and Defendant David M. Vieth 2, PC defrauded the United
States, the Commonwealth of Virginia, the District of Columbia, the State of Georgia, and the
State of Maryland by making, and the Defendant Dentists defrauded the United States, the
Maryland by causing Defendant KS-VAP and/or Defendant Kool Smiles VAN; Defendant Kool
Defendant David M. Vieth 2, PC to make, false statements of the medical necessity of such
services in the HCFA 1500 forms for the resulting claims.
147. Dental Fillings Not Medically Necessary: By carrying out a policy to provide
dental fillings, regardless of the medical necessity of such services, Defendant KS-VAP and/or
50

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Case 3:16-cv-00369-JBA Document 36 Filed 09/21/15 Page 1 of 50

UNITED STATES OF AMERICA.

v. FIRST AMENDED COMPLAINT

Comes now the Plaintiff, and for its action, states:

covered by those programs.

4. Defendant Kool Smiles DC PC owns and operates a dental clinic in Washington,

materials provided to persons covered by those programs.

for services and materials provided to persons covered by those programs.

the United Statesof America, in compliance with 31 U.S.C. § 3730(e)(iv)(B)

JURISDICTION AND VENUE

occurrences as the counts brought under § 3730 of the FCA.

PARTIES TO THE ACTION

12. Defendant Candler Road Dental, PC is a for-profit professional limited liability

"Kool Smiles" name.

was originally owned by a separate one of the above non-surviving entities.

youths eligible for Medicaid.

wholly-owned by Defendant Candler Road Dental, PC.

16. Defendant Kool Smiles DC PC is a for-profit professional limited liability

defendants as "Hechinger" at 1531 Maryland Avenue. Washington, DC 20002 (the "D.C.

DC, PC is wholly-owned by Defendant Candler Road Dental, PC.

18. NCDR, L.L.C. (hereinafter, "Defendant NCDR") is a for-profit limited liability

herein as the "Kool Smiles Companies."

20. Defendant Sara Abolahrari, D.D.S. ("Defendant Abolahrari") is a dentist licensed

0401411860. Defendant Abolahrari is a resident of Virginia Beach, Virginia, was a Dentist of

to conclude that it is a mis-spelling of the legal name of Defendant KS-VAP.

employed by Defendant KS-VAP or Defendant Kool Smiles VAN in 2007.

22. Defendant Yolanda Robinson, D.D.S. (a/k/a Yolanda Price) ("Defendant

Robinson") is a dentist licensed to practice in the Commonwealth of Virginia since October 4.

also upon information and belief.

FALSE CLAIMS ACT

not, in fact, performed, or making misrepresentations in order to obtain payment of funds to

which a party is not entitled. 31 U.S.CA. §§ 3729 et seq.

Any person who-

the FCA. J4 § 3730(b).

Co.. 390 U.S. 228 (1968).

level of health care are legally false. These theories include:

certified compliance with a statute, regulation, or contractual term as a prerequisite to payment.

Presentation of a Medicaid claim on Health Care Financing Administration's ("HCFA") Claim

to sign certifications and representations of compliance with applicable law in applications to be

recognized as a participant in Medicaid, and to certify compliance in periodic reports and

statements required to remain a participant. These certifications are therefore preconditions to

implication, claims filed after the violation are false.

VIRGINIA FRAUD AGAINST TAXPAYERS ACT

presentation of false claims to the Commonwealth of Virginia.

32. The VFATA imposes civil liability on:

Any person who:

(a) [k]nowingly presents, or causes to be presented, a false or fraudulent claim for

on behalf of the Commonwealth. Id. at § 8.01-216.5.

VIRGINIA'S MEDICAID DENTAL PROGRAM AND FAMIS

include claims submitted under both of these programs.

Medicaid dental services in the Commonwealth of Virginia.

be of a quality which meets professionally recognized standards of health care." 42 U.S.C. §

1320c-5(a)(l); 42 C.F.R. § 1004.10(a).

"medically necessary." 42 U.S.C. § 1396a; 42 C.F.R. § 440.230(d).

medical, dental, behavioral, rehabilitative or other health care services which:

Medicaid] policy or failed to maintain adequate documentation in support of their claims." In

Service Agreement containing this text.

DISTRICT OF COLUMBIA FALSE CLAIMS ACT

presentation of false claims to the District of Columbia.

41. The DC FCA imposes civil liability on:

Any person who:

(1) Knowingly presents, or causes to be presented, a false or fraudulent claim for

(2) Knowingly makes, uses, or causes to be made or used, a false record or

statement material to a false or fraudulent claim; [...]