Home Practice ManagementInsurance Audits and Frauds: Two Words No Dental Office Wants To Hear.

Audits and Frauds: Two Words No Dental Office Wants To Hear.

by partica

When was the last time your office was audited? Have you ever considered what Fraud is? How it affects the dental industry as a whole? Or perhaps you are part of the profession who feels that if you have not signed up with Medicare you will not be audited.

Did you know that the United States General Accounting Office reports that health care fraud adds at least 10 percent annually to the nation’s health care costs? 1 In an effort to curb fraud, they monitor all claim submissions received and rely on various tools to uncover questionable reporting, over-utilization and potential fraud schemes. Yes, potential fraud schemes.

Fraud not only drives up the cost of dental coverage for your patients, it can directly affect your practice. Understanding fraud can help you keep your practice safe. Let us take a moment and explore how we can help keep you and your practice safe and worry free from any potential of Fraud, using correct in-house auditing.

If I were to ask you about an abbreviation called an NPI, would you know what that means? When I teach at the dental school level, students must learn how to fill out a dental or medical claim form which has their NPI on it. That NPI is trackable to the doctor even if the payment went to the patient. After years of billing, I must turn down patients who write to me to bill for work their doctor did not, or did not know how to, correctly fill in their NPI. I wish I could help them, but I cannot fill out a form without their doctor’s NPI.

There is a lot that we must learn, and in-house auditing can help you learn a lot of the legal issues that surround your office. When you learn how to do auditing, including identification of incomplete or inadequate documentation/ paperwork, missed billing opportunities, issues that can result in recoupments (even criminal prosecution), and a host of other issues, this helps reduce and eliminate fraud. Understanding what the signs of fraud are can be the first step to change.

Fraud is not only what happens with insurance but also how the office is managed. Fraud comes in many forms and we will address what can happen when we are not the leaders of our own business. Let’s review the signs of fraud and how it can possibly appear in your office.

The following are signs of fraud that can occur in a dental office setting:

    • Routine failure to collect the patient’s full payment or share of cost without notifying the carrier
    • Concealing other available coverage
    • Misreporting dates to circumvent calendar year maximums or time limitations
    • Submitting claims for covered services when non-covered services are provided
    • Providing unnecessary services
    • Patients who use another person’s ID to obtain benefits
    • Limiting the availability of appointment times when compensation is capitation-based

Make note that not all the signs are about in-network. If you report a different date or did not document the need for treatment and how you diagnosed that patient, you could have been providing unnecessary services. Insurance looks at all parts of the form, not just who has in network ability.

When people ask me if I were to sum up fraud in one word, I always say “documentation.” A dentist’s work is only as good as his documentation. When teaching at resident programs I ask the audience if they are still writing a short book or have they started to “text message”-style their documentation. Yes, I am kidding when I ask that… but it is true! How are you documenting? Unless you have scrutinized your records, you may not know what skills you and your team need to carry out today’s billing issues or what is needed when an audit takes place.

A chart audit can help increase your efficiency by demonstrating your professionalism, knowledge of Standards of Care, knowledge of dentistry, and your understanding and compliance with regulatory requirements, all of which will lessen the likelihood of malpractice claims, dental board sanctions, or monetary recoupments by the people/organizations that pay your bills.

As dentists and medical care professionals, we are lifelong students of our profession. In addition to learning about changes in dentistry, you handle everything that happens in your office by every team member. Audits have shown me that we need the entire team trained on billing, documentation, legal issues of signed forms, and so much more.

Sometimes fraud comes in predictable forms and other times it is less obvious, but fraud always leaves traces. I know your office is busy and your team members may feel overwhelmed, but that is why the Insurance Extravaganza is the one meeting you should attend this year. There has never been a meeting such as this and there is no official training like this in dentistry. You and your team will have a better understanding as to why you need to supply each form needed, understand what insurance should be billed (dental or medical), and the legal issues surrounding your treatment plans.

Our speakers are teaching state laws, ADA help with contracts, negotiations, diagnostic/coding, documentation and so many amazing tips to success.

1National Health Care Anti-Fraud Association, 2008

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