WASHINGTON - The letter sent to Texas Gov. George W. Bush carried a pointed message. Dentists in his state were unnecessarily performing more expensive procedures on poor children to earn higher reimbursement, a former Medicaid investigator alleged.
Bush, who has benefited from large donations from the state dentist lobby, replied to the 1997 letter by instructing a top aide to look into the allegations and take ''whatever action you deem appropriate.''
Three years later, former Medicaid investigators who worked during Bush's tenure say little has changed to keep poor children from getting unnecessary work, like more expensive crowns when all that's needed are fillings.
''What scares me is the lack of concern by the governor's office about fraud in the Medicaid dental program,'' said Bob Olson, who was the Texas attorney general's senior Medicaid fraud investigator for 12 years until his retirement in 1997.
Bush's chief health and human services commissioner defends the administration's record.
''I feel we are recovering significant amounts of dollars and doing everything within our power to impress on the provider population there will be consequences'' for fraud, Texas Health and Human Services Commissioner Don Gilbert said in an interview.
Gilbert's agency notes it recovered $1.8 million in improper payments from dental providers in the fiscal year that ended Aug. 31, and is in the process of collecting $3.5 million more in payments and penalties. Twenty-three dentists have been excluded from Medicaid in Texas since 1998.
Critics say the more expensive crown procedure can carry greater risks because children sometimes have to be anesthetized. At least three poor children in Texas have died during the procedures during the 1990s.
Pediatric dental experts say the more durable crowns can be a good solution for children who receive care infrequently.
The practices of the Medicaid dentists have raised concerns across Texas.
Two Medicaid dental investigators were removed from their jobs under Bush's administration after influential dentists complained about aggressive audits.
Officials in Galveston, Texas, discovered a group of roving dentists this summer who were performing procedures on indigent children using a bus equipped like a dental office. Police said the dentists used a computer linked to state records showing how much money children had left in their Medicaid accounts. State officials concluded the dentists were bilking Medicaid.
The Houston Chronicle has reported extensively about the practice. And a judge ruled this summer that Texas failed to fulfill a 1996 agreement to make major improvements to its Medicaid program and wasn't adequately caring for 1.5 million low-income youngsters.
An Associated Press review of state figures shows Texas continues to provide a much larger number of crowns to Medicaid patients compared to other big states.
In fiscal 1999, Texas paid for 548,600 fillings and 227,300 crowns - a ratio of one crown for nearly every two fillings. In comparison, Illinois paid for 208,500 fillings and just 10,500 crowns - a nearly 20-to-1 ratio. And Pennsylvania dentists had 69,200 fillings compared to just 5,600 crowns - a more than 10-to-1 ratio.
Texas dentists receive between $68.75 and $85.51 for stainless steel children's crowns, compared to $27.30 for a single-surface filling and more for additional surfaces.
A battle has raged in Texas between state investigators, who viewed the practice as profit-driven, and the state's powerful dental lobby, which funneled $100,000 to Bush's gubernatorial election efforts.
The controversy began as Bush was taking office in January 1995.
On the day of Bush's inauguration, a prominent children's dentist complained about state audits of Medicaid dentists conducted by Dr. Harold Seiler, chief investigator for the state's Medicaid contractor.
Dr. William Steinhauer of San Antonio, Texas, who lodged the complaint, said in a recent interview that Seiler was trying to ''second-guess clinicians who had more qualifications than he did.'' Within a month, Seiler was fired.
Seiler expressed his concerns about the program in numerous memos to Bush. On Aug. 30, 1997, he asked: ''Why are dentists the only group of providers in the Medicaid program to be paid an incentive to treat patients at a higher level of service?''
Three weeks later, Bush referred Seiler's allegations to Gilbert and urged him to take ''whatever action you deem appropriate.
''I appreciate your attention to this matter,'' the governor wrote.
Bush's administration also was hearing complaints from dentists.
In 1998, then-president of the Texas Dental Association, Dr. Stephen Schwartz, met with Gilbert to complain about unannounced audit visits to dental offices that were ''very disruptive to providers and smelled a little bit of a lack of due process.''
The chief state dental reviewer, Dr. Don Crow, soon found himself out of a job. The Bush administration said Crow's firing had nothing to do with his work. Instead, the state accepted the dentist lobby's suggestion to replace the investigator with a panel of experts.
Other state officials also raised concerns.
Beth Taylor, who quit as director of the Texas attorney general's Medicaid Fraud Unit in December 1998, wrote Gilbert that the ''prevailing sentiment'' in the Medicaid program was ''the customer is the Medicaid provider instead of the ... recipients.''
And in 1997, the longtime enforcement director for the state Board of Dental Examiners, Santos Serna Jr., resigned, saying he was told to alter a report implicating state-employed dentists in Medicaid fraud.