I just bought a dental practice. Can I bill under the last doc's provider number until I get mine?3/8/2016 There is a very short answer to this one: don’t do it. And if it is a government program: Really don’t do it. I know, it hurts – especially when that overhead seems to grow almost exponentially and you have patients ready and willing to partake of the dental magic that you perform. But, unless you are convinced that orange jumpsuits are your thing, there are a few compelling reasons to work around the inconvenience. Let’s begin by calling it what it is: insurance fraud. If you do the work, but then tell the payor that someone else did the work in order to get paid, you have probably committed insurance fraud. There are a couple of limited scenarios under certain programs where the primary doctor is allowed to act as the supervising clinician and bill for work that he did not actually perform. The clincher is that the supervising clinician must be present when the procedure was performed. Although some Medicaid programs allow this “supervising clinician” exception, be very careful to verify the allowance before you bill. Any dentist providing services to Medicare and Medicaid patients opens the door to criminal charges and penalties subject to the anti-fraud and abuse requirements of those programs. That is a big deal – civil charges typically follow fraud claims and result in fines and penalties. Criminal charges, however, result in jail time and a record that is likely to pop up far more often than the National Practitioners Databank (more on that monstrosity in future posts). Do an Internet search on “dentist Medicaid fraud” and it will become evident that the government does not mess around. While some of the accounts are egregious (see US v. Zamani where there were $21 million dollars of questionable Medicaid charges billed under associate Zamani’s license over three years) others are much less so. Consider the recent case of Alfred Fairbanks in Washington. Dr. Fairbanks was found guilty of four instances of Medicaid fraud and sentenced to a $100,000 fine, 90 days in jail, 200 hours of community service, and a five-year probation. At sentencing, the judge said to 69 year old Fairbanks: “This is a sad day, you are clearly a pillar in your community.” There is no minimum threshold for the government – the value of Dr. Fairbank’s four erroneously or fraudulently billed fillings were likely worth less than $500. There is also no safe harbor for unintentional billing or confusion in the intent of the code. For example, another case found a doctor guilty of using the wrong exam code, even though the one he used more accurately described what he had actually done. See US v. Lamb. The 20 instances over 4 years could not have amounted to more than an $800 difference in payment, but resulted in probation, jail time, and a huge fine. Know what you are getting into as a Medicaid provider and, whatever you do, do not bill under another provider’s number. There aren’t nearly as many cases of legal precedent when it comes to insurance companies suing doctors in the same scenario. Probably has something to do with the myth of the “preferred provider.” Without the criminal component, the potential gain for insurance companies is much smaller, and, being insurance companies, they have already lobbied for legislation to protect themselves. As you already know from experience, or from colleagues, insurance companies may routinely audit charges and request reimbursement for overpayments. (Check your state laws at http://www.medclaimsint.com/Documents/Insurance%20Recoupment.pdf, as most must make the request within 12 months of the bill.) However, whether caught by the insurance company, or not, insurance fraud is never a good idea. Consider the heart-stopping moment when you receive a complaint from your state dental board demanding a patient chart. The last thing you want is for anything to be amiss in that chart, especially not your name in the chart notes and someone else’s name in the billing record. So, what can you do in the situation? The first thing to do is call the insurance provider as soon as there is the possibility of purchasing or associating at the practice. They will give you directions. If it is not Medicaid, ask them if you can get an exception to bill under the previous provider’s number until you get your own – the worst they can do is say “no.” If they do say yes, make sure you get it in writing. Also, private insurance companies have the ability to expedite these requests. I have seen associate dentists get approved within a week of applying for their own provider numbers and privileges. Remember, orange is not your color. If it feels like it can come back to bite you, it probably can. Unlike a standard of care violation, fraud is a character allegation. From a legal perspective, this incident could create a character precedent that can be used against you in any future case, whether related to dentistry or not. Try to protect yourself by smart practices. If you have any questions, call us. If you have already been accused, definitely call us – this is the one you want to fight hard.
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March 2016
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