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RAISING THE REIMBURSEMENT ROOF WHILE REDUCING REGULATORY RISK roy_shelburne@hotmail.com www.royshelburne.com 276-346-3863 1

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ROYS DISCLAIMER: I am not an attorney The comments and observations made in this presentation are not to be taken as legal advice The material shared is based on my understanding of best practices The information I share is my opinion and is based on my experience and subsequent research I cannot promise that implementing the systems I recommend will ultimately prevent legal action

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TODAY'S LEGAL ENVIRONMENT Malpractice Claims Insurance companies have become much more concerned with identifying, penalizing, and prosecuting healthcare fraud Board of Dentistry Actions: Most citations are related to record keeping

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LEGAL DEFINITION OF INTENT Blind Disregard Who is ultimately responsible?

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INSURANCE Conventional (Indemnity) PPOs HMOs Direct Reimbursement Discount Plans

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I hereby certify that the procedures as indicated by date are in progress (for procedure that require multiple visits) or have been completed ADA C LAIMS F ORM L ANGUAGE

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T REATMENT P LAN $1,000 5% C ASH D ISCOUNT $ 950 What goes on the form? $1,000 or $950? D ISCOUNTED F EE FOR P RE - PAYMENT

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D ISCLOSING C O -P AY F ORGIVENESS All states prohibit co-pay forgiveness without third-party notification. Virtually all PPOs prohibit co-pay forgiveness! If you forgive the co-pay in an isolated situation, the remarks section should read: The patient is not participating in the cost of treatment. Note: Always disclose fee forgiveness to third-party.

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STATE AND ERISA PLANS Insurance (only applies to insured plans under State Insurance Commissioner, not self-funded plans of large employers ERISA) Employee Retirement Income Security Act of 1974 (ERISA)Retirement Income Security

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ERISA T YPE P LAN Employment Retirement Income Securities Act (ERISA) a Federal Law. Controls accident and health plans and retirement plans of self- employed and employers benefit plans. Self-funded, not insured plans, are under ERISA. Self-funded plans are often larger employers. Can fee cap for non-covered procedures.

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P ROMPT P AYMENT L AWS Passed by all states Clean Claim is one with all fields completed and complies with payers filing (published) requirements. Clean Claims must be paid in 30/60 days, according to state law. Prompt Payment Laws do not apply to self-funded (ERISA) plans. Some PPO self-funded contracts spell out the prompt payment policy, however.

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BILLING FOR OPTIONAL SERVICES Check with the carrier Discuss with the patient Signed agreement from the patient Use the correct corresponding code D_999 code Regular code Attach a copy of the agreement with the claim

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OPTIONAL SERVICES Limitations on All Benefits - Optional Services that are more expensive than the form of treatment customarily provided under accepted dental practice standards are called Optional Services. Optional Services also include the use of specialized techniques instead of standard procedures. For example: a crown where a filling would restore the tooth; a precision denture/partial where a standard denture/partial could be used; an inlay/onlay instead of an amalgam restoration; a composite restoration instead of an amalgam restoration on posterior teeth. If you receive Optional Services, Benefits will be based on the lower cost of the customary service or standard practice instead of the higher cost of the Optional Service. You will be responsible for the difference between the higher cost of the Optional Service and the lower cost of the customary service or standard procedure.

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RECORD KEEPING LAW AND RECORDS RETENTION LAW The ADAs Recommendations

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C AN YOU LEGALLY... Charge different fees for different people? Charge different fees for different plans? Charge different fees for same procedure code? Charge different fees for non-insurance patient versus PPO Insurance patients?

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WHAT DELTA TELLS THE PATIENT: If the Dentist discounts, waives or rebates any portion of the Enrollee Coinsurance to the Enrollee, Delta Dental will be obligated to provide as Benefits only the applicable percentages of the Dentists fees reduced by the amount of such fees that is discounted, waived or rebated.

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FEE REDUCTIONS Discounting Co-pay forgiveness laws Ethical Considerations

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P ATIENT G IFTS FOR R EFERRAL Prohibited by many states law. Prohibited by Medicaid or government- funded program.

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CREDENTIALING Name on the claim form as provider of service

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FEES In-network charges Out of network charges

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PPO CONTRACTS Several pages only Refers to procession policy manual Provide emergency care

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PPO CONTRACTS Agree to lower of PPO fee, or the practices unrestricted fee Agree to same clinical protocol Agree to non-discriminatory patient appointment times

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PPO CONTRACTS Agree to provide any and all information requested Agree to audit on premises

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PPO CONTRACTS Audit paybackif audited, associate must pay back money in 90 days. Agree to offset of payment in slow pay/disputes Can terminate with 30/60 days Malpractice requirements and limits Contract can be modified unilaterally by insurance company with 30/60 days notice Upgrades to basic PPO covered services

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AADC Diagnostic Software Continuous Audits Standard Deviations Chart Reviews Fraud Flags

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WHERE ARE YOU?

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WHO GET AUDITED? Those who participate with PPOs You have not choice. You must cooperate Those who do not participate with PPOs You have a choice Bear the consequences

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AUDITS, WHAT TO EXPECT? In network or out of network? Audits are performed to determine: That the procedure was performed That the procedure was medically necessary That the procedure was not cosmetic

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AUDITS Audits are performed to determine: That the fee charged was the same fee charged to non-insurance patients in similar circumstances That the clinical protocol for non-insurance patients was the same clinical protocol for insurance patients in similar circumstances That the procedure is not up-coded Example: A surgical extraction (D7210) is charged instead of a routine extraction (D7140).

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AUDITS That the claim form was accurate That the procedure was properly represented by the current CDT - 2013 code reported Rights if non-participating

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TOP CODES UNDER REVIEW 1. D4341, Periodontal scaling and root planning, four or more teeth per quadrant

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TOP CODES UNDER REVIEW 2. D1110/D4910 on the same patient

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TOP CODES UNDER REVIEW 3. D2950, Core build-up, including any pins

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TOP CODES UNDER REVIEW 4. D7210, Surgical removal of erupted tooth requiring removal of bone and/or section of tooth

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TOP CODES UNDER REVIEW 5. D2391, Resin-based composite, one surface posterior

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TOP CODES UNDER REVIEW 6. D2335, Resin-based composite, four or more surfaces or involving incisal angle (anterior)

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TOP CODES UNDER REVIEW 6. X-raysof any kind

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TOP CODES UNDER REVIEW 7. Impactions

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SERVICES UNDER REPORTED: D0180: Comprehensive Periodontal Evaluation New or Established Patient This procedure is indicated for patients showing signs or symptoms of periodontal disease and for patients with risk factors such as smoking or diabetes. It includes evaluation of periodontal conditions, probing and charting, evaluation and recording of the patients dental and medical history and general health assessment. It may include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occusal relationships and oral cancer evaluation.

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REATTACHMENT OF A TOOTH FRAGMENT, INCISAL EDGE OR CUSP D2920

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RESIN INFILTRATION OF INCIPIENT SMOOTH SURFACE LESIONS D2990 Placement of an infiltrating resin restoration for strengthening, stabilizing and/or limiting the progression of the lesion

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D4341/D4342 AND D4910 Perio Scaling and Root Planing Periodontal Maintenance Do the math:

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PERIODONTAL MEDICAMENT CARRIER WITH PERIPHERAL SEAL LABORATORY PROCESSED D5994: A custom fabricated, laboratory processed carrier that covers the teethe an alveolar mucosa. Used as a vehicle to deliver prescribed medicaments for sustained contact with the gingiva, alveolar mucosa, and into the periodontal sulcus or pocket: Perio Protect

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PALLIATIVE: D9110 Palliative (Emergency) Treatment of Dental Pain Minor Procedure This is typically reported on a per visit basis for emergency treatment of dental pain

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RECORD KEEPING ABOUT RECORD-KEEPING - BE DEFENSIVE. If it is not in the clinical record 1. It was not seen 2. It was not said 3. It was not heard 4. It didnt need to be done 5. It wasnt done 6. It doesnt existfrom the legal perspective

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CLINICAL RECORD AND THE CLAIM They should mirror one another The Clinical Record should record pertinent information and should justify and support the treatment Evaluation X-rays What was observed that helped in the treatment planning process Anything surprising

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P RIMARY -S ECONDARY I NSURANCE Only determines the sequence of insurance billing. Make no adjustment to patients account until after secondary has paid. Primary-secondary status does not determine the patients responsibility. The patients responsibility is determined by the lower of the contracted fee schedules. Primary payer for a child is determined by which parent whose birthday comes first in the calendar year. The birthday rule can be overridden by a court order (Divorce Agreement).

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COORDINATION OF BENEFITS Write-offs when to take them? COB test

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THE MOST COMMON FRAUDULENT ACTS Billing for services, procedures, and/or supplies that were never provided or performed. The deliberate performance of medically unnecessary services for the purpose of financial gain. Source: National Health Care Anti-Fraud Association (www.nhcaa.org).www.nhcaa.org

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THE MOST COMMON FRAUDULENT ACTS Intentionally misrepresenting any of the following, for purposes of obtaining a paymentor a greater paymentto which one is not entitled: The nature of services, procedures, and/or supplies provided or performed The dates on which services and/or treatments were rendered ; Source: National Health Care Anti-Fraud Association (www.nhcaa.org).www.nhcaa.org

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THE MOST COMMON FRAUDULENT ACTS The medical record of service, and/or treatment provided The condition treated or the diagnosis made; The charges for services, procedures, and/or supplies provided or performed; The identity of the provider or the recipient of services, procedures, and/or supplies. Source: National Health Care Anti-Fraud Association (www.nhcaa.org).www.nhcaa.org

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MALPRACTICE CONSIDERATIONS Deviation from the standard of care AND Injury Does stuff happen? Inform Handle the situation appropriately

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FAILURE TO DIAGNOSE An evaluation indicates that a diagnosis has been established or that arrangement to determine the diagnosis has been made: Periodontal conditions Oral lesions

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PRESCRIPTION MONITORING PROGRAM:

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WHAT DO WE DO NOW? Honest Assessment Meet with the team Determine where you are Decide where you want/need to be Develop a plan Set your standards You get what you accept, not what you expect Train Trust Review

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Thank you! www.royshelburne.com www.royshelburne.com 423-552-6111 email: roy_shelburne@hotmail.com