So, what’s the take home?
It’s not just a Medicaid issue. If the
practice provides care to anyone whose
treatment is subsidized in any way with
government monies, the same rules
apply. These patients include Medicaid,
Medicare, federal employees, dependents
of active duty military personnel and
those covered by affordable health care
plans. In addition, conventional insurance
carriers are becoming more concerned
with potential fraud and abuse and
have become more aggressive in
actions against physicians and dentists.
I had always understood the definition
of intent to defraud to refer to those
situations where there was a claim
submitted for services that were never
provided for patients who were never
seen…and certainly, that is intent to
defraud, but it also includes instances
where there is “blind disregard.” Blind
disregard includes those instances
were errors are made with no systems
in place to identify and correct those
errors. Literally, this means that igno-
rance of the errors is not an excuse. Is
perfection exp ected and necessary?
Absolutely not. It does imply, however,
that there should be active systems in
place in the practice to identify and
correct errors that are made and protocols
established to insure that those mistakes
do not continue to happen.
I had always thought that if I received
any monies I was not entitled to, I could
return it along with any penalty and or
interest due without further action.
That’s not the case. The best “offer” I ever
received to settle the dispute was to
spend 3 years in prison and pay
restitution of nearly $300,000.
Where are we today as a profession?
Every practice and practitioner
undergoes continuous audits via
electronic “surveillance” methods.
Carriers review the submission histories
of the provider doctors on a continuous
basis and compare those histories to the
submission history of other providers.
The global frequencies derived from all
submissions are plotted on a bell curve.
Doctor “average” is squarely in the
middle of the bell curve. The doctor
who falls one standard deviation to the
right of the center of the curve may
receive a letter from the carrier that
informs that doctor that (s)he is doing
more crowns that their peers. The
greater the distance the doctor is from
the center of that curve, the greater the
chance of the “random” audit.
There are certain procedures that the
carriers believe are being “abused.”
Those codes are the subject of closer
scrutiny and increase the likelihood of
further review if the submission
frequency is deemed suspicious.
Should dentists live in fear?
Absolutely not….unless proper
documentation, billing and
coding, and quality assess-
ment/quality improvement
systems are ignored.
Can what happened to me be prevented
from happening in other offices and to
other doctors? Absolutely, if the proper
steps are taken to establish systems and
protocols that are designed to support,
protect and defend.
Don’t miss the opportunity to
learn more at Dr. Shelburne’s
session on April 27, 2018, at
Pennsylvania’s Dental Meeting
in Hershey.
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