Triad Oral Surgery (Stefan J. Simoncic, D.D.S.)

High Point, NC 2015--2019 Dental Practices

North Carolina Attorney General North Carolina Medicaid Investigations Division Medicaid Fraud Medically Unnecessary Procedures False Claims Inadequate Clinical Documentation

Penalty

$567,125

Outcome

Triad Oral Surgery and Dr. Stefan J. Simoncic paid $567,125 to settle North Carolina Medicaid fraud allegations involving claims for oral evaluations and anesthesia services that were not medically necessary, lacked clinical documentation, or violated Medicaid policy between 2015 and 2019.

Details

Triad Oral Surgery — Operation Root Canal Medicaid Fraud Settlement (2019)

Outcome: Triad Oral Surgery and Dr. Stefan J. Simoncic paid $567,125 to settle North Carolina Medicaid fraud allegations involving claims for oral evaluations and anesthesia services that were not medically necessary, lacked clinical documentation, or violated Medicaid policy between 2015 and 2019.

Triad Oral Surgery was operated by Dr. Stefan J. Simoncic, D.D.S., in High Point, North Carolina. The practice was an oral surgery specialty practice that performed procedures including extractions and surgical interventions on Medicaid recipients. The North Carolina Attorney General's Medicaid Investigations Division investigated the practice as part of Operation Root Canal.

The state alleged that between January 1, 2015, and August 31, 2019, Dr. Simoncic and Triad Oral Surgery submitted claims to the North Carolina Medicaid program involving detailed oral evaluations and anesthesia services performed on Medicaid recipients. The state alleged these services were not medically necessary, did not have supporting clinical documentation, or were performed in violation of Medicaid policy. The specific focus on evaluation codes and anesthesia services billing indicated a pattern of systematic over-claiming for pre-procedure and sedation services beyond what Medicaid covered.

Operation Root Canal represented a coordinated enforcement initiative targeting dental Medicaid fraud patterns across North Carolina. Through the initiative, the Medicaid Investigations Division reached settlements with 10 dental providers, recovering more than $6.3 million for the Medicaid program in total.

The settlement was announced September 24, 2019. Triad Oral Surgery and Dr. Simoncic agreed to pay $567,125 — the largest individual settlement in the Operation Root Canal initiative — to resolve all allegations without a finding of liability.

Primary Source: Attorney General Josh Stein Announces Operation Root Canal Medicaid Settlement — NCDOJ

How Crucible Prevents This

Crucible's clinical documentation controls enforce the linkage between anesthesia billing and documented patient medical necessity assessments. For oral surgery practices billing anesthesia services to Medicaid, Crucible's procedure-code validation rules require supporting anesthesia records, patient risk assessments, and clinical justification — preventing claims from being submitted without these prerequisites. Automated monitoring of evaluation codes and anesthesia billing ratios against case volume would flag anomalous patterns consistent with the allegations in this case before Medicaid investigators identify the discrepancies.

Source: Attorney General Josh Stein Announces Operation Root Canal Medicaid Settlement — North Carolina Department of Justice (Sept. 24, 2019)

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