The ADA dental claim form is a legal document. The claim form is the instrument by which a practice coveys complete and accurate information to a payor for reimbursement. Any misrepresentation made on this claim form may have legal repercussions AND no specific intent to misrepresent the information is necessary to be considered guilty of fraud. That just doesn't sound right, does it? No specific intent to misrepresent the information is necessary to commit fraud is necessary to be guilty of fraud????? What??? I invite you to read: http://oig.hhs.gov/compliance/physician-education/roadmap_web_version.pdf, a government publication directed toward training medical professionals. The government notes that: "You do not have to intend to defraud the Government to violate the False Claims Act. You can be punished if you act with deliberate ignorance or reckless disregard of the truth. This means you cannot hide your head in the sand and avoid liability." This "hard nosed" stance is nonetheless the "legal" definition of intent. Deliberate ignorance or reckless disregard can be view as intent to defraud. Literally, ignorance is no excuse whether submitting a claim to the government, Delta Dental, or Met Life. Specifically, the date of service matters, the fee charged for the service matters, the provider who is identified as providing the service matters, and the representation of the service provided matters. Any misrepresentation of the information from the practice to the payor via the claim form whether electronic or paper is a legal document and must be treated with the same respect as any other document. If you have questions as to what is acceptable and what is not acceptable should be asked and answered before submitting a claim. Your future and the future of your practice could depend upon the respect by which you treat the dental claims process. It does matter and blind disregard for the truth can come back to "bite" you.
Just finished another audit and the issues remain the same. "The documentation does not support the treatment provided." This doctor faces significant financial loss. The entity is asking for repayment for the "unjustified" services and the demand is substantial. OUCH!
If it's not in your dental record, you didn't see it, you didn't say it, you didn't do it, it didn't need to be done, and it doesn't exist from a legal perspective. Be careful to document in such a way that there's no question left unanswered, no service provided left to the imagination. The dental record should read like a story that has a beginning, middle, and end where everything is recorded. I know, I know. There are only so many hours in a day, but ask this doctor who will most probably write a six-figure check. The time taken to document completely would have been very well spent and could very well have prevented this action. When you are tempted to cut corners in your recordkeeping, billing, and coding systems weigh the consequences and choose wisely. Defending yourself and your practice....priceless.
For help in bringing your systems up to speed, give me a call. I'm on your side and here to help!
If you have any questions or concerns It would be a pleasure to talk with you. I'm truly here to help. My greatest hope is that no one else will suffer the same fate as myself. Please contact me for a complimentary 30 minute consult. That call may be the one that can change your fate.Ask yourself this question. If the court comes knocking at your door (or in my case, knocking down your door) are you set to protect and defend yourself and your practice?
Your protection and defense can come by way of:
- Your clinical records
- Your systems, due diligence, and internal reviews
- Independent audits
Contact me to discuss what can be done for you so that you can be prepared if facing a legal challenge. It is imperative that your records and systems are able to stand alone in your defense. It would be my pleasure to custom design, with you, a system that suits your practice and method of operation.
Don't wait until the prosecution is at your door. At that point, it's too late.