How Medicare fraud suspensions work for dentists
When Medicare or Medicaid suspects a dentist of billing fraud, they do not when ready revoke your license. Instead, they typically suspend your ability to bill those programs — which means you cannot receive payment from Medicare or Medicaid for any patient care, even legitimate treatment. Your dental license itself remains active, but your practice income from those programs stops while an investigation proceeds.
The suspension usually comes as a written notice from the Office of Inspector General (OIG) or your state Medicaid agency. The notice will specify which programs you are suspended from (Medicare, Medicaid, or both), the reason for suspension, and the date it takes effect. You will also receive information about your right to request a hearing to contest the suspension.
A billing suspension is different from a license suspension. Your state dental board may investigate separately and take action against your license itself — but Medicare's action is about payment, not your right to practice. Many dentists continue treating patients during a billing suspension, but they must collect payment directly from patients rather than billing the programs.
Key Takeaways
- Medicare or Medicaid billing suspensions prevent you from submitting claims to those programs, but do not automatically revoke your dental license.
- The suspension notice will come from the OIG or your state Medicaid agency and will explain the reason, the effective date, and how to request a hearing.
- You can continue treating patients during a suspension if you collect payment directly, but billing the programs during suspension can result in additional penalties.
- Requesting a hearing within the timeframe stated in the notice is your main opportunity to challenge the suspension before it takes effect.
- Your state dental board may investigate the same conduct separately and take independent action against your license.
What triggers a Medicare or Medicaid billing suspension
Medicare and Medicaid suspend dentists for patterns of billing that suggest fraud or abuse. Common reasons include billing for services not rendered, billing for more expensive procedures than what was actually done, submitting duplicate claims, billing for procedures on the wrong tooth or surface, or billing for preventive services more frequently than program rules allow.
The programs use data analytics to flag suspicious billing patterns. If your claims stand out — for example, if you bill for root canals at a rate far higher than other dentists in your area, or if you consistently bill for four bitewings per patient when program rules allow two — you may be selected for review. A claims reviewer will then examine a sample of your submitted claims against patient records.
You do not have to be convicted of a crime for Medicare to suspend you. The programs can suspend based on investigation findings alone. However, they must give you notice and an opportunity to be heard before the suspension becomes permanent.
The notice you receive and what it requires
The suspension notice is a formal document that will arrive by certified mail. It will include the specific allegations (for example, "billing for prophylaxis more frequently than program guidelines permit"), the time period under review, and the effective date of the suspension. The notice will also state whether the suspension is temporary pending investigation or whether it is based on completed findings.
The notice must include information about your right to request a hearing before an administrative law judge. This is your main opportunity to present your side of the case. The notice will specify a important date — usually 60 days — by which you must request the hearing in writing. If you do not request a hearing by that important date, the suspension may become permanent without further review.
Keep the notice and all related documents. You will need them if you request a hearing, and you will need them if you later work with an attorney or accountant to respond to the allegations.
Requesting a hearing to contest the suspension
To request a hearing, you must submit a written request to the address listed in the suspension notice before the important date passes. Your request does not need to be lengthy — it can be as straightforward as a letter stating that you request a hearing and want to contest the suspension. Send it by certified mail so you have proof of delivery.
Once you request a hearing, the suspension may remain in place while the hearing is scheduled and conducted. Hearings can take several months to schedule. During this time, you cannot bill Medicare or Medicaid, but you can continue treating patients and collecting payment directly.
At the hearing, you will have the opportunity to present evidence, call witnesses, and respond to the allegations. Many dentists hire an attorney or a healthcare compliance consultant to represent them at the hearing. The administrative law judge will issue a decision, which can uphold the suspension, modify it, or overturn it. Either side can appeal the judge's decision to a higher level within the federal system.
What happens to your dental license during a billing suspension
Your state dental board operates independently from Medicare and Medicaid. A federal billing suspension does not automatically trigger a state license investigation, but it may prompt one. If the state board learns of the suspension — through the OIG's public exclusion list, through a complaint, or through routine monitoring — they may open their own investigation into whether you violated state dental practice laws.
State boards typically investigate whether you committed fraud, gross negligence, or violations of the state dental practice act. The standards and procedures vary by state. Some states move quickly; others take a year or more. If the board finds a violation, they can impose discipline ranging from a warning letter to license suspension or revocation.
It is possible to have a federal billing suspension lifted while a state board investigation is still pending, or vice versa. The two processes are separate, and the outcomes do not have to match. You may also face civil or criminal charges from the Department of Justice or your state attorney general, which is yet another separate process.
Continuing your practice during a suspension
If you are suspended from Medicare and Medicaid billing, you can still treat patients who pay out of pocket or through private insurance. You must not submit any claims to Medicare or Medicaid during the suspension — doing so can result in additional penalties, including civil recovery of overpayments and potential criminal charges.
You should notify your patients that you are temporarily unable to bill Medicare or Medicaid and explain what payment options are available. Some patients may choose to seek care elsewhere; others may be willing to pay directly. You can also continue treating Medicaid patients if you refund any Medicaid payments you received and collect payment directly from the patient instead.
During the suspension, document everything carefully. Keep detailed records of patient visits, the treatment provided, and how payment was collected. If the suspension is eventually lifted, these records will help you demonstrate that you continued to provide appropriate care and did not attempt to circumvent the billing rules.
Working with legal and compliance professionals
If you receive a billing suspension notice, consider consulting with an attorney who specializes in healthcare fraud defense or a healthcare compliance consultant. These professionals can review the allegations, help you prepare for a hearing, and advise you on how to respond to the investigation.
An attorney can also help you understand whether you face criminal exposure. If the OIG investigation is part of a broader criminal investigation by the Department of Justice, you may need criminal defense counsel in addition to someone handling the administrative suspension hearing.
A compliance consultant can review your billing practices, identify any patterns that may have triggered the suspension, and help you implement corrective measures. If your suspension is lifted, demonstrating that you have made changes to prevent future problems can help protect you from future investigations.
Frequently Asked Questions
Can I bill private insurance while suspended from Medicare and Medicaid?
Yes. The suspension applies only to Medicare and Medicaid. You can continue billing private insurance and treating patients who pay out of pocket. You must straightforward avoid submitting any claims to the suspended programs.
What is the OIG exclusion list and will I be on it?
The OIG maintains a public list of excluded providers — people and practices barred from receiving payment from federal healthcare programs. If you are suspended, you may be added to this list. Being on the list is public information and can affect your reputation and your ability to work with certain employers or facilities.
How long does a billing suspension usually last?
There is no fixed timeline. Some suspensions are lifted after investigation findings show no wrongdoing. Others last until you complete corrective action or repay disputed amounts. Some become permanent. The length depends on the nature of the allegations and the outcome of any hearing or appeal.
Do I have to repay money if the investigation finds billing errors?
If the investigation finds that you overbilled Medicare or Medicaid, you will likely be required to repay the overpayment amount. This can happen even if the overbilling was unintentional. Repayment is often a condition of lifting the suspension.
What if I disagree with the allegations but cannot afford an attorney?
You can represent yourself at a hearing, though this is not recommended for complex cases. Some state bar associations maintain referral lists for attorneys who offer reduced-fee representation. You can also contact your state dental association to ask whether they offer resources or guidance for members facing investigations.