Start Out on the Right Foot! Donald P. Lewis Jr., DDS, CFE

Like all areas of the health care profession, practicing dentists are under scrutiny by government agencies, insurance companies and other regulatory and governing bodies. To protect themselves, dental professionals have to be aware and focus on dental fraud and abuse. Scrutiny or dental health-care fraud and abuse is not likely to change because of the current economic and political environment.

Most dentists are professional, caring, ethical and honest. The majority of practicing dentists would

never knowingly consider participating in any

type of dental fraud, abuse, or

“Beware and Be Aware” Understanding

Dental Health-CareFraud and Abuse

scam. As a new practicing dentist, you need to diligent to dental fraud and abuse. Your practice could be committing dental fraud without your knowledge, but nevertheless you can be held accountable for the result of the actions of your employees.

In a recent case, an employee was committing insurance fraud, by submitting false claims and having the remittance sent directly to the employee’s address. Although the practitioner did not commit the fraud, the fraud was still being committed by his practice. The amount of liability resulting with the practitioner is a legal matter, and an attorney should be consulted. In this case, the practitioner was liable for the refunding

Having just started your practice, you have worked too long and too hard to allow fraud and abuse to occur. Unfortunately, like any type of business, there is a small but disturbing number who are dishonest. While is can be difficult at times to determine the source of the fraudulent activity, the picture that is being painted is disturbing in situations of fraud, negligence and unethical treatment.

the monies falsely remitted and is under investigation by state authorities. Dental professionals must realize that any claims submitted by their office are their responsibility whether or not they have direct knowledge of the claims submission.

So what is dental fraud and abuse? By definition, dental fraud is any act of intentional deception or misrepresentation of treatment facts made for the purpose or likelihood of gaining unauthorized benefits. Acts of dental fraud involve three defining features, which include intent, deception and unlawful gain. These acts involve deceitful practices that are not identified as acceptable and legitimate financial practices. Fraud in the dental profession happens when fraudsters with the means and opportunity take full advantage to unjustly profit.

These scams can include, but are not limited to, billing for services not rendered, misrepresenting dates of service, waiving of deductibles and/or co-payments, incorrect diagnoses or procedure codes, over-charging for routine services, or unbundling of procedures. Let’s examine each of these a little closer. 1. Billing for services not rendered – Billing for services that have never

been provided or rendered is a common type of dental fraud and abuse.

or deductible results is looked at as overbilling the insurance company. Dentists that are not reducing their fee when they do not collect patient payments are in essence charging inflated fees to the insurance company. Using the inflated fees is considered to be making up for the amount of money lost by waiving the copayment or deductible. Most government health care plans and insurance companies don’t allow providers to waive patient’s deductibles or co-payments. The providers will sometimes justify the waiver of the deductible by saying that they don’t make any extra profit by doing this, there are just helping out their patient who can’t afford to pay balance or co-payment. However, by waiving the coinsurance or copayment the insurance company often ends up paying expenses that they shouldn’t have to pay which results in higher premium costs for policy holders. 4. Misrepresentation of services, incorrect diagnoses, or procedure codes – Providers that bill for false diagnoses or procedures performed could be in the form of changing the code to increase the amount of the claim reimbursement. This also will decrease the patient’s

By definition, dental

fraud is any act of intentional deception

or misrepresentation

of treatment facts made for the purpose

or likelihood of gaining unauthorized

benefits.

For example, the case of a dentist that merely examined the patient but billed for more expensive dental services, including fluoride and sealants. 2. Misrepresenting dates of service – Misrepresenting the dates of service provided is a fraudulent act. The date of the procedure is important to the insurance companies as there may be a waiting period prior to benefits being available. In other instances, the date of service may be changed to take advantage one way or another of the early deductible requirement. The date of service and the date that

the dental claim is signed should be the same. Changing the date of service should never be done, as this is dental fraud and abuse. 3. Waiving of coinsurance or copayments – Accepting insurance as payment in full and disregarding the coinsurance payment, copayment,

maximum benefit and increases the patient’s out-of-pocket expense. This type of fraud was brought to light when a dentist was providing surgical procedures that were misrepresented. It seems that the provider was performing routine dental extractions and using the procedure code for impacted teeth. It was revealed when the insurance company noticed that the same radiograph was being provided for each patient, with the name being changed! 5. Unbundling of procedures – The American Dental Association (ADA)

defines unbundling of procedures as “the separating of a dental procedure

into component parts with each part having a charge so that the cumulative

charge of the components is greater than the total charge to patients who are not beneficiaries of a dental benefit plan for the same procedure.” This scenario is represented by a dentist that was unbundling his procedures to make the total charge increase. For a simple extraction of a tooth, the dentist was charging for not only the extraction, but also for elevating the flap, curetting out the periapical tissue, incision and drainage that was in conjunction with the extraction, and finally for suturing of the socket site. These procedures are all part of the global fee for extraction of the tooth and should not have been unbundled. 6. Upcoding – Upcoding is defined by the ADA as “reporting a more complex and/or higher cost procedure than was actually performed.” The practice of upcoding procedures to bypass insurance company reimbursement limitations and increase practice income is certainly being watched by insurance companies and regulatory agencies. For example, in a case where the perpetrators, without the knowledge of the dentist, coded the services rendered to a higher code to increase the revenue to the practice they managed in order to increase their – or that of their employees – incentive compensation. Based on an anonymous tip, an investigation was started by one of the large insurance carriers which resulted in the ongoing monitoring of the claims submitted by the practice. 7. Performing unnecessary procedures – Performance and billing for treatments not needed or for proving additional services or procedures beyond what was required to increase billings and claims amounts.

The bottom line is that we live in a dangerous and unscrupulous world and need to be diligent to protect our assets and reputations. As a young dentist, you need to be schooled on the business side of the practice and need arm yourself with the tools and resources to protect your new

business. The following suggestions are simple and include:

Fraud Examiner” (CFE) from the Association

of Certified Fraud Examiners. He is a highly respected and sought-after lecturer on the subject of white-collar crime.

Seek training on what to look for in your practices daily operations • Obtain the best tools to run and control the business side of your practices, software, analytical tools, etc.

Dr. Lewis´s passion to protect business owners

from white-collar crime led him to establish PATedLLC®, of which he is the Founder and CEO. Practice SafeGuardTM is PATed´s first

ƒƒ Note that the tools you have are

only as good as the level you and your team’s working knowledge of the functionality the systems offers. In other words use the training offered by the software providers. • Use the reports your operating systems provide so you are aware of the alerts and trends you need to understand what is happening with your practice. • Obtain qualified Certified Public Accountants, lawyers, trainers and

product, and is the only platform dedicated to fraud and embezzlement detection in the healthcare industry.

He is also a Professor of Oral and Maxillofacial Surgery at Case Western Reserve University School of Dental Medicine.

In his spare time, Dr. Lewis is a high school

basketball official, and three times has officiated in the Ohio High School Athletic Association State tournament finals in Columbus, Ohio.

advisors to provide you with the necessary oversight and advice you need. • Run background checks on all employees prior to hire or after reading this article if you have not done so previously. Starting your dental practice is the culmination of many years of study and sacrifice. Make sure that you start out with protecting yourself from becoming a victim of dental fraud and abuse. ■

He is a former agent of the U.S. Internal Revenue Service and the Defense Contract Audit Agency of the United States Department

of Defense. He is also Regent Emeritus of the Association of Fraud Examiners, a member of

Donald P. Lewis, Jr., DDS, CFE is a Diplomate of the American Board of Oral and Maxillofacial Surgery (AAOMS) and is currently in private practice as a leading oral and maxillofacial surgeon in Cleveland, Ohio.

the American Management Association´s PanAsian Council and is on the Board of Directors

of the Cleveland Council on World Affairs.

Mr. Farragher´s global spread of clients include domestic and foreign government agencies, government contractors, private and public corporations, not for profit organizations and international development agencies. He lectures on fraud awareness, detection and investigation programs at corporate, university, accounting and legal communities all over the world.

He holds a Bachelor of Science degree in Chemistry from Valparaiso University, his Doctor of Dental Surgery (DDS) from Case Western Reserve University School of Dentistry, and his

post-graduate Residency in Oral and Maxillofacial Surgery at The University Hospitals of Cleveland.

After losing over $100k to fraud in his practice,

Dr. Lewis earned the designation of “Certified

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