Fraud and AbuseProfessional misbehavior

Background.—Governmental agencies, insurance com-panies, and other regulatory agencies watch health carepractitioners carefully to ensure that patient data and prac-tice information are secure and standards of conduct arebeing met. However, cases of fraud and abuse are unfortu-nately common, even though most dentists are profes-sional, caring, ethical, and honest. When the dental staffengages in misdeeds or is negligent, the dentist, as a profes-sional and a business owner, is the one considered respon-sible. They are also responsible for the informationrecorded in their names when they permit the misuse of in-formation to occur without a regular audit and liable for allclaims submitted by their office, whether or not they havedirect knowledge of them. The tactics and behaviors thatconstitute fraud and abuse must be recognized and stepstaken to avoid such misbehavior.

Fraudulent and/or Abusive Dental Practices.—Acts ofdental fraud are characterized according to intent, decep-tion, and unlawful gain. With respect to billing, every profes-sion suffers fraud related to billing for services notprovided. The dates of service and of the claim signaturemust be the same. Insurance companies often have waitingperiods before benefits are available, and the dental officemay delay dates of service to take advantage of early deduct-ible requirements. Dentists who do not reduce their feeswhen they waive patients’ deductibles essentially areinflating their fees to the insurance company, which isillegal. Most government health care plans and insurancecompanies forbid dentists to waive patient deductibles orcopayments. When a coinsurance or copayment is waived,the insurance company is billed for expenses they wouldnot pay otherwise, and the result is higher costs passedalong to all patients. Incorrect diagnoses or inaccurate pro-cedure coding is fraudulent and can raise the possibility ofliability. Codes changed to increase the reimbursementamount decrease the patient’s maximum benefit and in-crease out-of-pocket costs.

Another fraudulent practice is the unbundling of proce-dures. Essentially the procedure is separated into compo-nents that are then charged for individually, resulting in acumulative charge for patients without dental coveragethat is greater than the charge for the complete procedurepaid by patients who are covered by dental plans.

Upcoding refers to the reporting of a more complex orhigher-cost procedure than the one actually performed,which bypasses the insurance company’s limit on

reimbursement. Staff members should never be given in-centives for certain procedure codes, or this abuse canbecome a standard practice. Another procedure-relatedabuse is performing unneeded tasks or going beyondwhat is necessary to increase the amount that can be billed.

Although violations of the Health Insurance Portabilityand Accountability Act of 1996 (HIPAA) Section 231 arenot criminal, violators face enormous fines, penalties, andexclusion from certain health care programs. The penaltyamounts for the Civil Monetary Penalties Law (CMPL)have jumped from $2000 to $10,000 per violation and applyto each claims form line item or prohibited practice.

Protecting Against Fraud.—To avoid having to facepenalties or worse for illegal practices or fraud, the dentistshould become educated about the possible ‘‘red flags’’raised when staff members are involved. Many software ap-plications are available to monitor transactions in accountsand detect fraudulent activities. It is also important to knowthe practice’s employees and when they are in financial orfamily difficulty and could be tempted to ‘‘fudge’’ the re-ports. All prospective employees should be carefully vetted,with complete background checks performed routinely.Current management systems provide reports that shouldbe carefully studied to detect alerts and trends. This willhelp the dentist better understand the business aspects ofthe practice. If fraudulent activities are suspected, thedentist should hire qualified certified public accounts, law-yers, trainers, and advisors to analyze the situation expertlyand determine what is going on.

Clinical Significance.—It’s your practice andyou need to know what’s going on. Ratherthan leave all the paperwork to the staff, it’simportant to maintain oversight of all opera-tions through software or regular audits bytrusted professionals. Know your staff and befamiliar with everything that goes on in theoffice as well as in the operatory.

Lewis DP Jr, Farragher GP: Dental health-care fraud and abuse. DentEcon vol 103, issue 12

Reprints available from DP Lewis Jr; e-mail: DLewis7109@aol.com

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