4.8.16 Issue #735 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Belle DuCharme, CDPMA
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Lack of Front Office Training Can Lead to Insurance Fraud and Abuse
By Belle DuCharme, CDPMA

“I was only doing what the doctor asked me to do” explained the office manager of a practice undergoing an insurance company audit. On several occasions, the office manager, who was in charge of billing the dental claims, would approach the dentist for explanation of charges that didn’t fit any of the codes in the current CDT manual. The dentist told her to choose a code that “would get the claim paid” and use the “right words” to document the treatment. The dentist did not write any clinical notes that actually supported the codes the manager chose to bill to the insurance company. The dentist never looked at any outgoing claims.

When the audit was being performed, the patient records chosen to analyze did not correctly support the billing codes and the other records were not complete, such as radiographs or intra oral photos that would have documented what was performed. Without the proper documentation to support the claims, the dentist was told “If it isn’t documented it didn’t happen.” 

The dentist maintained that procedures were performed, but the insurance company said they were not a benefit of the policy. Patients called the office reporting that the insurance company said the dentist was not using the “right words” or “right codes” to get the claims adjudicated in their favor. To please the patients, the manager had chosen codes and inflated claims to get the insurance company to pay. She thought it was a game and the insurance companies were “out to get the dentists” by making it impossible to get paid for work that was done for the patient. The office manager in this case was ill-informed and did not know she was committing fraud in the name of the dentist and the practice.

According to the American Dental Association, “Dental insurance fraud is any crime where an individual receives insurance money for filing a false claim, inflating a claim or billing for services not rendered.”

If a service is rendered but then billed as something else to get it paid, that is also insurance fraud. A practice that routinely bills for examinations that will be covered 100% by the insurance company but then does not do the examination is guilty of fraud.   Fraud comes in many forms, but is often driven by a lack of training and knowledge of the person who is in charge. Often the charge of fraud is downgraded to abuse because it was not the intention of the manager or dentist to deceive the insurance company to get paid. In situations involving insurance fraud, the dentist and manager can be convicted and possibly fined and sent to prison.

What can you do as a professional dental practice to thwart this seemingly innocent but definitely wrong way of handling insurance billing? Bending the law in the guise of helping the patient is taught by well-meaning clinicians to their staff, and it needs to stop. When the staff member moves on to another office and observes that the behavior is considered unethical, they suddenly realize they have been involved in unsavory business practice. This has a trickle-down effect in the dental community as the word gets out of insurance billing abuse.

Proper training in the rules and regulations involved in filing dental insurance claims is set forth in every dental insurance provider contract that a dentist signs to participate in-network, but very few dentists read the contract. Proper coding information is widely available and the best sources are provided by Tom Limoli with his Documentation, Coding and Claims Manual, or you can use Dr. Charles Blair’s Coding with Confidence Book. You can also get the Current Dental Terminology Book from the ADA.  

Each one of these sources is excellent and has something special to offer those who document and file dental insurance claims. Front Office Training and Dental Office Manager Training through McKenzie Management are very explicit in content on insurance filing, and the courses are provided by knowledgeable and senior consultants with years of experience filing “clean claims” to insurance companies.

If you would like more information on McKenzie Management’sTraining Programs  to improve the performance of your team, email training@mckenziemgmt.com

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