Dr. Emmanuel Olutayo Delano.
A dentist with two practices on St. Croix is petitioning the court because the Department of Human Services has refused to reinstate Medicaid payments the agency says were suspended due to suspicions of fraud. The dentist, however, says DHS has no credible evidence with which to undergird these suspicions.
According to his petition, Emmanuel Olutayo Delano operates St. Croix Dental, which offers general dentistry, and Toothworks VI, a specialty practice focused on the soft tissue inside the teeth. “Both offices are licensed and certified to treat Medicaid patients in the Virgin Islands," the petition states. However, a “non-medical record review” in 2022 resulted in a finding of “credible allegations of fraud,” and in March 2024 DHS suspended payments to the practices.
DHS said that there were “claims paid for services possibly not rendered, dates of service on closed days, and beneficiary sharing,” pointing to these issues as evidence of fraud. However, these findings were “subsequently refuted,” according to Dr. Delano’s petition. A request for reconsideration failed, with DHS in April of this year affirming its decision to suspend Medicaid payments to St. Croix Dental and Toothworks.
The agency did concede that two of the eight records that were under suspicion had been corrected. The DHS also acknowledged that Dr. Delano had “refuted all allegations against Providers,” but still maintained their decision to suspend.
The dentist is challenging that decision in the court, arguing that under local and federal laws and regulations, the difficulties DHS is having with the six records that remain under suspicion do not rise to the level of a credible allegation of fraud. DHS also reportedly found that several rejected claims were resubmitted in a suspicious manner, including some in which provider names were switched. However, Dr. Delano’s petition highlighted that much of the confusion stems from difficulties in using the Virgin Islands Medicaid Medical Management System (VIMMIS). When attempting to submit claims, either the system would not allow the selection of the correct provider, or an approved provider would not show up in the system at all, he argued. It was DHS who instructed the practice to submit claims under an incorrect provider name until VIMMIS issues were resolved, he said.
The petition also claims that the lack of clear, local guidelines in the use and management of the VIMMIS system results in an ad hoc approach which “in effect penalized providers due to DHS lack of consistency.” Relying on the guidelines established by national dental associations is not good enough, Dr. Delano claims, since neither the American Dental Association nor the American Academy of Pediatric Dentistry should be considered the arbiters of a “standard of care” for the territory.
Residents of St. Croix who rely on Medicaid to underwrite essential dental services are already underserved, argued Dr. Delano. The continued suspension of payments to his two practices, for what he says are no valid reasons, makes it even more difficult for the most vulnerable Crucians to get the services they need. He is asking that the courts reverse the decision of DHS and order that Medicaid contracts be “fully and unconditionally” reinstated.
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