Avoid Insurance and Billing Fraud

Paul Bornstein DMD

Sponsored by Renaissance Systems & Services

MY WEBSITE http://www.paulbornsteindmd.com

THE PROBLEM• Fraud can occur unintentionally, or occasionally to pad a

practice bottom line, but it occurs more often than dental professionals would like to admit. However, insurance companies are utilizing scrupulous auditors and sophisticated computer software to find fraudulent billing and collect on overpayments. In the worst case scenarios, the owners and billing staff of these practices are being charged with health care fraud, being imprisoned, fined and their licenses are being revoked. Don't let an innocent mistake affect your professional, financial, and personal future.

In a nutshell, any variation in the charting, coding and billing from an insured patient and a non insured patient is going to be an irregularity. All too often the differences in how documentation and billing are done are not by intent but rather by ignorance. Under no condition is it ever appropriate to chart, code or bill based upon the absence or presence of an outside non-patient payer. just a few examples include of "insurance irregularities" would include but not be limited to: -any canned program of surgical / non-surgical periodontal care -multiple claims for the same date of service -restorative add on's such as anesthesia, pulp caps, cement bases, metal or aesthetic upgrades, etc -some services billed on claims while others are not -discounts on patient copays -free exam and x-ray (but we charge the insurance) -inlays billed as onlays or 3/4 crowns -laser gingivectomy with crown prep rather than cord -laser prophy as opposed to or as add on to scale and polish -D?999 procedure codes as add on to regular fee -not generating claims after the patient has reached their annual max -radiography taken but specific diagnostic finding not logged in the clinical chart -alternating D1110 and D4910

WHAT IS FRAUD• Submitting for services that were never performed.• Misrepresenting the actual treatment rendered in an attempt to gain benefits.• Misrepresenting treatment dates in an attempt to gain benefits.• Misrepresenting the teeth numbers and/or surfaces that work was performed on in an

attempt to gain benefits.• Billing insurance companies more for a service than what is charged on the patient ledger.• Misrepresenting the diagnosis to justify payment for certain services.• Dental offices that do not charge or collect full co-payment, deductibles, or extend discounts

and fail to disclose it on the submitted claim.• Falsifying treatment and/or financial records.• Billing for cosmetic services as medically necessary procedures.• Submitting claims for services performed by unlicensed individuals.• Dental offices/patients that conceal other insurance coverage that would pay for services on

the claim form submitted (medical, dental and/or workman's compensation).• Misrepresenting the identities of patients/subscribers/providers.

Fighting fraud is everyone's responsibility: patients, brokers, employers, and providers. Did you know these are signs of fraud?•Submitting for services that were never performed.•Misrepresenting the actual treatment rendered in an attempt to gain benefits.•Misrepresenting treatment dates in an attempt to gain benefits.•Misrepresenting the teeth numbers and/or surfaces that work was performed on in an attempt to gain benefits.•Billing insurance companies more for a service than what is charged on the patient ledger.•Misrepresenting the diagnosis to justify payment for certain services.•Dental offices that do not charge or collect full co-payment, deductibles, or extend discounts and fail to disclose it on the submitted claim.•Falsifying treatment and/or financial records.•Billing for cosmetic services as medically necessary procedures.•Submitting claims for services performed by unlicensed individuals.•Dental offices/patients that conceal other insurance coverage that would pay for services on the claim form submitted (medical, dental and/or workman's compensation).•Misrepresenting the identities of patients/subscribers/providers.•Individuals who misrepresent their identity by using another individual's insurance.•Placing a non-covered person on your policy by misrepresenting their relationship to you.

  

IF YOU SUSPECT FRAUD CALL OUR ANTIFRAUD UNIT

IF IT IS NOT IN THE RECORD IT NEVER HAPPENED

IF IT IS NOT IN THE RECORD,YOU DID NOT SEE IT,YOU DID NOT DO IT,IT DID NOT NEED TO BE DONE, AND IT DID NOT EXIST-FROM A LEGAL

PERSPECTIVE. In other words, if you completed a thorough exam, made a definitive diagnosis, devised a comprehensive treatment plan that

addresses the pathology, obtained informed consent, and presented patients options, but then failed to record this information in the clinical

record-from a legal perspective-you never performed an evaluation

DO THE NOTES TELL THE STORY?

If you see a fee schedule and have to try to

come up with ways to get around the fee allowed in order to get what you feel to be a reasonable reimbursement, you have not signed up for an appropriate plan for your practice. Know how to pick and choose plans that fit your practice goals.

On August 17, 2000 the CDT Code was named as a HIPAA standard code set. Any claim submitted on a HIPAA standard electronic dental claim must use dental procedure codes from the version of the CDT Code in effect on the date of service. The CDT Code is also used on paper dental claims, and the ADA's paper claim form data content reflects the HIPAA electronic standard.

Components of a Dental Code1. CODE- A five character alphanumeric code beginning with the

letter “D”…….

2. NOMENCLATURE- A written, literal definition of a Dental Procedure Code.

3. DESCRIPTOR- A written narrative that provides further definition and the intended use of a Dental Procedure Code.

RESTORATIVE CODES

D2391 resin-based composite—one surface, posterior

Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not a preventive procedure.

D1351 Sealant—per tooth

Mechanically and/or chemically prepared enamel surface sealed to prevent decay.

DELTA

Restorative services shall be benefits when dentally necessary and when carious activity has extended through the dentoenamel junction (DEJ).

D1352

NEW CODE

preventive resin restoration in a moderate to high caries risk patient – permanent tooth. Conservative restoration of an active cavitated lesion in a pit or fissure that does not extend into dentin; includes placement of a sealant in any radiating non-carious fissures or pits.

UCCI RULE

In order to qualify for benefits the following conditions must exist:

1.Probing depths must be 5mm or greater.2.Radiographs must show attachment loss with

the appearance of reduction of the alveolar crest beyond the 1 -1 1/2mm proximity to thecemento-enamel junction (CEJ).

D4341 Periodontal scaling and root planing---four or more contiguous teeth per quadrant

This procedure involves instrumentation of the crown and

root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as part of pre-surgical procedures in other.

AMERICAN ACADEMY OF PERIODONTOLOGY

There are many types of periodontal diseases. The followingis an overview of the most common:

GingivitisAs the mildest form of the periodontal diseases, gingivitiscauses the gums to become red, swollen, and bleed easily.

There is usually no discomfort at this stage.Chronic Periodontitis

Chronic periodontitis is a condition resulting in inflammation within the soft tissues surrounding the teeth causing progressive attachment and bone loss.

It is diagnosed by bone loss on a dental X-ray, the formation ofgum pockets and/or receding gums. It is most common in

adults, but can occur at any age.

RETROSPECTIVE REVIEWSAMPLE LANGUAGE

A participating dentist authorizes DDTN to deduct from any payments due him/her such sums as DDTN reasonably determines to be properly due and owing to DDTN as a refund of payments incorrectly made to or claimed by the dentist for which the dentist has not refunded the amount due.

THE LATEST PROCESS AVAILABALETO THE INSURANCE INDUSTRY

Easy to use graphical user interface Data cube technology for maximum

flexibility in slicing and viewing the data o Assess utilization by patient age,

gender, region and specialty Create standard reports or customize

individual reports for specific needs Profile individual providers based on

utilization ratios that assess o Overutilization o Upcoding o Unbundling o Quality of Care o Fraud and Abuse

Focused review - claim review based on identification of providers who are upcoding, unbundling or overutilizting ADA codes that are not included in standard referral guidelines

Create your own utilization ratios or choose from our standard ratios

Individual provider score based on claim review denial information

Easy to read graphics enable you to drill-into individual provider detail

Compare to national and regional benchmarks

Cross payer longitudinal database for fraud detection

THE CASES I HAVE BEEN INVOLVED IN!

Indictment: Dentist filed false claims for insurance

– They are charged with defrauding insurance companies of about $2.3 million.

– While the indictment says Villalobos allegedly was doing work on patients in Juárez and billing U.S. insurance companies from addresses in El Paso, the charges have nothing to do with where services were provided.

False Claims Act/Qui Tam Current developments in whistleblower lawsuits brought under the False Claims Act and other newsMonday, December 20, 2004Massachusetts charges dental corporation with Medicaid fraud Massachusetts has brought both criminal charges and a civil suit alleging violation of the state's Medicaid False Claims Act against a dental corporation. The False Claims Act suit alleges that DR.---------submitted phony bills for services that were never provided and "unbundled" services, charging separately for procedures that should have been billed together at a reduced cost.

The Massachusetts Attorney General's Office issued a press release on December 15, 2004.

The Claim Form

DELTATreating provider number. If there is more than one dentist at a service office, enterthe provider number of the dentist who performed the service.

ADA Claim Form

3. No Balance Billing or Cost ShiftingMany enrollees realize significant out-of-pocket savings from our industry-exclusive "no balance billing" provision prohibiting network dentists from billing Delta patients for any difference between their submitted charge and the amount Delta allows (i.e., the maximum plan allowance). Enrollees only have to pay deductibles and copayments required by their employer's plan.In addition, network dentists cannot bill Delta Dental patients for charges Delta Dental does not allow, such as "unbundled" services that should be billed as one procedure - so there's no "cost shifting" to enrollees. Enrollees know the maximum amount they'll pay and are protected from unexpected charges.Delta Dental of Illinois has a sophisticated adjudication system that automatically compares procedures reported on claims in progress with those previously processed in claim history. When deviations are identified, claims are suspended for review by a dental auditor with expertise in dental treatment.

Many dentists unbundle (i.e., split procedures into component parts) in order to generate additional fee income. This is one of the many areas where Delta's cost management expertise pays major dividends for its clients.All procedures affected by unbundling have been entered into a special system edit table that automatically disallows the component procedures while allowing the appropriate bundled procedure.As the nation's premier dental benefits carrier, Delta Dental has used dental consultants representing each region of the country to develop standard processing policies. These uniform rules apply to all dentists in Delta Dental's networks so when unbundling occurs the enrollee is protected from inappropriate charges.An important cost-savings is that Delta Dental Premier and Delta Dental PPO network dentists cannot shift these costs, i.e., balance bill, Delta patients for disallowed amounts.

DELTA OF ILLINOIS

Beware of offers to waive coinsurance/copayment amounts Your dentist has just offered to give you a discount. She is going to accept your insurance as payment in full and not collect your coinsurance/copayment amount from you. This may sound like a great deal, but it’s not. Here are a few reasons why:

Accepting your insurance as payment in full and disregarding your coinsurance, copayment or deductible results in overbilling the insurance company. It's against the law in many states and is viewed by the dental profession as unethical. It’s also a violation of the dentist's contract with Delta Dental.

Dentists are not reducing their fee when they do not collect patient payments. Instead, these dentists are charging inflated fees to the insurance carrier to make up for the money they lose from waiving the coinsurance/copayment amounts.

Enrollees who knowingly agree to the dentist's scheme are participating in this deception.

No matter how irresistible the offer of "free" dentistry seems, the care you receive really isn't free. As a result, it increases costs and your present dental plan may become too expensive for your employer to offer.

Delta Dental takes overbilling very seriously, and we use a variety of methods to fight it. However, all our anti-fraud methods are not enough without your cooperation. If your dentist is waiving your coinsurance/copayment amounts, or if you have any other suspicions that your dentist might be overbilling, please report it to Delta Dental’s Fraud Hotline at 800-526-1852. You may remain anonymous.

REQUIREMENTS FOR PARTICIPATION CLAIMS SUBMISSION Dentists must certify that the services listed on the treatment form have been personally provided to the member by the dentist or, under their direction, by another person(s) eligible under DDSGP to provide such services, and such person(s) must be designated on the treatment form. The dentist must also certify that the services were, to the best of the dentist’s knowledge, necessary for the health of the member. The dentist must further acknowledge that they understand payment for services rendered will be made from Federal and/or State funds and that any falsification or concealment of a material fact may be prosecuted under Federal and/or State laws.

Cost-Shares

A cost-share is the amount you are required to pay for the services rendered. United Concordia pays a percentage of the dentist’s usual charge up to United Concordia’s allowance for the covered service, subject to limitations. The percentage paid and the enrollee’s cost-share depend on the type of service received. Dentists are required to collect cost-shares for certain covered services. Failure to collect cost-shares for covered services could disqualify the dentist from participating in United Concordia’s dentist network.

ADA Code of Ethics

ALABAMA DICIPLINARY ACTIONFor the purposes of this section irregularities in billing shall include: reporting charges for the purpose of obtaining a total payment in excess of that usually received by the dentist for the services rendered; falsely reporting treatment dates for the purpose of obtaining payment; falsely reporting charges for services not rendered; falsely reporting services rendered for the purpose of obtaining payment; or failing to advise and that the co-payment provisions of a contract have been abrogated by accepting the payment received from the third party payer as full payment.

2012 by DateSeptember 13 Boston MASeptember 14 Hartford CTSeptember 20 Long Island NYSeptember 21 Manhattan NYOctober 25 White Plains NYOctober 26 Paramus NJNovember 8 AZ BOOT CAMPNovember 9 Phoenix AZNovember 29 Tampa FLNovember 30 Miami FLDecember, 6 Portland ORDecember 7 Seattle WADecember 13 Torrance CADecember 14 Santa Clara, CA

2013 by DateJan 17 & 18 – Vegas Boot CampJan 30 & Feb 1 – Baton Rouge, LA & New Orleans, LA ( WED & FRI )Feb 7 & 8 – Shreveport, LA & Ft. Worth, TXFeb 14 & 15 – 2 Day Boot Camp in Anaheim, CAFeb 22 – FRIDAY ONLY – Charlotte, NCMarch 7 & 8 – Oklahoma City, Ok & Tulsa, OK March 15 – FRIDAY ONLY - Santa Monica, CAMarch 21 & 22 – Hartford, CT & Boston, MAApril 4 & 5 – Portland, ME & Manchester, NHApril 11 & 12 – Fairfax, VA & Baltimore, MDApril 26 – FRIDAY ONLY – Philadelphia, PAMay 2 & 3 – New York Boot CampMay 9 & 10 – Jacksonville, Fl & Orlando, FlJune 6 & 7 – Grand Rapids, MI & Lavonia, MIJune 13 & 14 - Milwaukee, WI & Minneapolis, MNJune 20 & 21 – Kingston Plantation, SC Boot CampJULY & AUGUST – N/ASept 18 & 20 – Little Rock, AR & Houston, TX ( WED & FRI ) Sept 26 & 27 – Chicago Boot CampOct 3 & 4 – Louisville, KY & Cincinnati , OHOct 10 & 11 – Columbus, OH & Indianapolis, INNov. 7 & 8 – Atlantic City Boot CampNov. 13 & 15 – Seattle, WA & Portland, OR ( WED & FRI ) Dec. 5 & 6 – Tampa, FL & Longboat Key, FL Nov. 29 – FRIDAY ONLY – St. Louis, MO

Dec 12 & 13 – San Francisco, CA Boot Camp