by Karen Kaiser, RDH
Risk management should be an integral component for practicing sound dentistry. In risk management, you review aspects of a practice for unsound areas that make it vulnerable to a subsequent lawsuit. When steps are taken to minimize risks, you safeguard yourself and the dental practice. As dental hygienists, we have professional obligations to render appropriate care to the patients entrusted to us. This care includes correctly documenting and maintaining dental charts. If you take undue risks with your chart entries, you may find yourself in a position of defending your ethical code and protecting your professional reputation when conflict arises.
I worked in a solo dental practice with a seasoned dentist who had been practicing for more than 20 years. His patients were loyal, and many had been a part of this practice for a long time. As the only dental hygienist, I was in a challenging position. With such a mature practice, quite a number of hygienists had previously provided treatment for these patients. My formidable task was to build rapport and gain the patients' confidence, a confidence that my employer had maintained for all those years.
At first glance, the practice appeared to be well-managed and very profitable for my dentist. Many of the patients accepted treatment without question and maintained a very faithful and frequent hygiene recare.
It wasn't until I had worked there for some time that I noticed a potential problem. My concerns were first raised because of the way patient charts were maintained.
In this office, it was understood that all entries to the patient records be completed in lead pencil. My doctor had been entering treatment he rendered to patients into the records this way for many years. At first, I wondered why a pencil was his choice for charting. I have been practicing in the dental field for 14 years and have always used permanent ink for charting purposes. Yet, not wanting to create a dispute, I followed in the footsteps of my dentist and his previous hygienists, and I began using a pencil too. In the back of my mind, I felt awkward and leery about using pencils to make entries because it was unfamiliar to me. I justified my feelings by telling myself that my employer must be under some type of grandfather clause for pencil entries because he had been practicing for many years.
Occasionally, I noticed dates seemed to be erased and changed to fit the patients' recare frequency. I speculated to myself on how to accomplish these modifications without causing billing confusion with insurance carriers. As time progressed, though, it became more obvious to me that what I entered as treatment was not always the treatment permanently recorded in the chart. As I began to establish a recare pattern with patients, I became more familiar with their charts and the entries regarding treatment provided. After investigating further, I became uncertain about the accuracy of my patients' charts due to the charting discrepancies I observed.
I began to question why treatment rendered did not always mirror the fees submitted to insurance carriers.
Curiosity and concern about the situation led me to discuss the issue with other dental professionals. Many of the colleagues I confided in also felt lead entries were questionable and all stated they made entries with ink. I approached a lawyer familiar with dental malpractice and casually asked his legal opinion on the "pencil" issue. He advised me that my doctor must follow the guidelines for what is current " standard of care."
After conversing with the lawyer, I became more unsettled about the pencil entries. I then attended a risk- management seminar, and the lecturers also discouraged the use of pencils due to its fallibility and questionable validity. Even with my new knowledge about pencil entries, I still gave my employer the benefit of the doubt, because I felt that he genuinely did not perceive a potential problem. Theoretically I believed that once I discussed my updated information on charting with him, he thenwould be inclined to make all chart entries in indelible ink.
Taking into account the legal advice I had received, I decided to go against my doctor's wishes. I again began making my chart entries with black ink as I had for many previous years. I felt no concern about the matter because I thought my doctor would understand my uneasy feelings and allow my entries to be in pen. I felt better with myself using a pen and believed my employer would applaud me for taking measures to keep him abreast of current standards.
After a busy morning working with patients, my doctor approached me about my charting and said harshly to me, "Do you need more pencils?" The look in his eyes alarmed me and his tone was stern. His demeanor puzzled me. I rebutted by calmly explaining my need to chart in permanent ink after seeking a legal opinion about the use of pencils. I also told him about the seminar — which, ironically, he had sent me to — on risk management that covered the topic of chart entries. The presentation discussed how easy fees and patient information can be changed if ink is not used.
I could not understand his protests over my request to use ink. His reply was that he was going to "do some checking" and that he would get back with me. He further stated that until that time, I was required to continue making entries with pencil.
When I arrived at work the following morning, I discovered, to my surprise, packages of ink pens on my counter. At first I was elated, but then I realized that the pens were erasable when I examined the packages. With much aplomb, my doctor approached me and said that I may now use these pens to do my charting. I suppose he felt that he had compromised by allowing me to use the erasable pens.
I began to wonder why this charting issue had stirred up so much uneasiness between us. Nevertheless, I disposed of the erasable pen caps. I felt that this would make it more difficult for others to change entries, even though I knew it would not make it impossible. Using these erasable pens pacified me, but I still was unable to commit the doctor and the rest of the office staff to follow in this compromised suit. The front office exclusively used red pencil to enter money transactions and my doctor continued with the lead pencil. By and by I once again settled into my dental hygiene routine. I was content to write with the erasable pens because I felt this was a slight improvement but I was still not pleased.
Soon, however, that contentment turned to resentment. One day my dentist asked me to erase my charting on several patients. This immediately sent up red flags. Why was I being asked to alter my entries? I had been using the erasable pens for several months without a dilemma.
My doctor took me aside and explained that he was now in the middle of a chart audit with an insurance company. He explained to me that we would need to "update" charts for this audit. This was new territory for me. In all of my dental experiences, I had not encountered this situation. In my mind, there was no way I was going to change any of the chart entries.
I then began to wonder how this insurance audit would encompass me.
In the days that followed, my doctor presented me with charts that needed altering. I told him firmly that I was not willing to change my entries. He was irritated at first. Then, in a calmer manner, he tried to convince me that no wrongdoing was committed by changing the charts. I was very confused by now, and I began to question the integrity of my doctor and the validity of his charts.
I became increasingly aware of my doctor's ethical problem as he attempted to draw me into the stratagem. Days later, after arriving at work, my doctor asked me into his office. He had been badgering me for days to alter certain charts. I had opposed his wishes, so he had been attempting to change my chart entries himself. He was irritated that the erasable pens did not erase completely. He decided to rectify his problem by requesting that I rewrite the entire page. He said that he would dispose of the original entries.
When I told him I was not willing to change anything, he replied that he would then change it for me. I realized that no matter what chart entries I made, they could and would be altered by my dentist. My doctor routinely reviewed my charts at the close of each day. I felt that if there were a conflicting issue, he would have approached me at that time instead of going back to change the charts at a later date. I knew these changes were not a result of the treatment I had performed, but a question of how it was billed.
I later discovered that my employer had a habit of submitting to the insurance company periodontal treatment when I only did a standard prophylaxis. He would keep patients on a three-month periodontal recare, even though they were never diagnosed with periodontal disease or had undergone any periodontal therapy. I was led to believe these same patients were very fortunate to have an insurance carrier that allowed unlimited prophies.
I brought the question of these perio claims to my dentist. He informed me that if I discovered any errors in prior claims that I should bring them to his attention and he would rectify them. Soon, I began to notice that past insurance claim forms were no longer a part of my patients' charts and I could no longer check for any inexactness. I realized something was wrong. The office now was trying to shield me from reviewing these claims sheets.
After realizing the extent of the inconsistencies with the billing, I was dismayed. I was not directly involved with insurance processing, so I was unaware of all of the potential infractions. Yes, there was a chance that the insurance audit would come to an uneventful close and things would return to normal.
But what if that was not the case and the dental review board was asked to intervene. My license could be at stake. I now feared that, if I were questioned under oath, it would be found that I knew what was occurring. The peer review committee might view me as a licensed hygienist involved in some scope of a coverup because I hadn't come forth sooner. I began to question my career and the ethics by which I practiced. It was at this point that I decided to take actions to protect my hygiene license and myself.
My first form of action was to solicit advice from other dental-care providers. It was suggested to me that I seek help and involve the state dental board and see what my options might. I contacted the dental board concerning my issues. Board members advised me that I could write a letter to the peer review board so they could begin investigating my doctor. They also told me another option would be to confront my doctor with what I suspected and force him into retirement.
I felt that it was not my duty to police my doctor or reach a decision on if what was occurring in the office was illegal. So, I opted to draft a letter to the state dental board and let them be the judge. I realized that once I formulated a letter and sent it to the board that my employment time at this practice might be limited. I drafted the letter andbegan my search for new employment.
I wrote an anonymous letter to the board. I did not realize that in doing so they would be slow in reviewing the matter. At that time I could not disclose who I was for fear of what may happen if the allegations proved somehow to be false. I made inquiring calls to the board yet felt like no progress towards an investigation was being made. I was beginning to feel as though this issue was not as immense as I first thought since the dental board did not seem interested. I increasingly became worried about what I should do next. If I let this charade continue I knew my principles would be forever changed.
I then decided to discuss the possible fraud with the insurance company that conducted the audit. I needed to understand the real reason why this audit was occurring. My co-workers did not feel the inquiry was of any significance and indicated to me that this was not the first time an insurance company had audited my dentist.
An informal meeting was arranged with an auditor. The interviewer I spoke with was interested in what I had to say and we exchanged information. I was unsure, though, if I disclosed anything relevant. But I learned from the insurance company many of the issues under investigation. The audit, I discovered, revolved around my doctor's orthodontic- and periodontal-case fees and the way they were being submitted for payment. We also discussed my employer forgiving insurance co-payments and only accepting what insurance paid as full payment. In the state were I practice, this forgiving of co-payment is illegal. There also were many discrepancies in regard to "insured" treatment we performed on patients. Home bleaching trays were routinely billed under mouthguard codes. My doctor also would also take a drill to a tooth, X-ray it, then submit a claim to the insurance that the tooth was defective and needed extensive work.
In this way, my doctor would maximize the patients' liberal maximum yearly benefits with his excessive fees. The insurance examiner explained that the information I provided would be reviewed and forwarded through the proper channels. Much of what I learned that day regarding the audit procedure alarmed me. I wondered if the aforementioned issues about treatment and fees would warrant punitive action, if brought before a dental peer review committee.
Back at work, I began to uncover evidence to protect my hygiene license from being affected by this audit. A part of my normal hygiene routine was now a quest to safeguard my career. My doctor continued to ask me to change entries and I continued to deny his requests. Stacks of charts were now on his desk. Every moment he was not with patients, he was in his office team reviewing the charts and making adjustments to entries.
On one such occasion, I was summoned to his office and he was in frenzy over one of my entries in particular. Although he knew of my objections to changing the chart, he again calmly asked me to change the entry. He also reiterated that if I did not want to change the entry that he would change it, and I shouldn't concern myself with it further. This time, however, in an effort to protect myself, I was armed with a cassette recorder. My intuition told me to be prepared for such a situation, so I covertly taped him asking me to alter the charts. If nothing else, I now had the proof I needed to protect myself and show my peers that what I stated was fact. I also came to the realization that I was the only member of the office who had the knowledge of ethics, power, and evidence to bring action upon my doctor.
It became increasingly difficult to providing routine care to my patients. My employer changed my perio charting in an effort to justify to the auditors claims he submitted showingthat many patients had ongoing periodontal disease. I can recall many patients who had 2mm or 3mm non-bleeding probe depths suddenly having 5mm or greater readings. I knew that my doctor had not performed periodontal evaluations on these patients and was intentionally trying to receive compensation for a more severe perio condition. My doctor accomplished these changes by having the front office falsify my original perio findings and submit erroneous readings to the insurance carrier.
Though difficult as it may be to understand that the front office would be a substantial part of this scheme, let me point out that the front-office manager was the doctor's daughter. In an effort to protect the office, the two of them pulled no stops to make it appear evident that they were assuming no faults for the payments they received for services from the insurance carrier.
The insurance company contacted me once more and informed me that I would be receiving an important phone call. The next channel of the investigation was activated. The case was now in the hands of the Federal Bureau of Investigation. To my amazement, I soon received the call and was asked to meet the next day with two agents during lunch. I was somewhat tense because it's not every day that one meets with the FBI. During this meeting I expounded on what was occurring from my personal experience and also informed them about the tape of my dentist asking me to alter chart information.
I played the tape recording for them to assess, and they attentively listened to the damaging information. They took possession of the tape and seemed pleased with what I had contributed. I felt confident that these kind and capable men would rescue me from this plight and I would no longer have to bear the situation alone.
I became a federal informant. I fully cooperated with the FBI and told them everything I knew. I was asked as part of the investigation to wear a recording device to work in the hopes of further obtaining evidence. I felt awkward recording conversations with my employer even though I had furtively done so previously.
I was not driven to trap my dentist but all prior attempts to discuss my concerns were rejected. My doctor was incorrectly assuming that I was loyal enough to his practice to allow the fraudulent acts to continue without saying a word. I was in no way benefiting from his billing concealment and furthermore felt he had endangered my hygiene license by his blatant dishonesty. Neither did I feel vile about uncovering lies to reveal truths.
The evidence against the practice was mounting. I collected original patient charts discarded in the trash or sent through the office shredder in an effort to dispose of them. I also found original perio charts that I had rendered — also discarded in the trash. Though time-consuming, I pieced these shreddings together and found obvious changes. I found the fraudulent charts in their places in the filing cabinets. I had made great strides to achieve merit in my dental career and felt sickened by how easy it was for this office to manipulate my self-worth by changing my chart entries. I now felt professionally violated.
As time passed, it became increasingly apparent that my doctor believed he would beat the insurance system with his altered replacements in the charts. Slowly, the high pressure of the audit appeared to diminish for him as fewer and fewer charts were piled on his desk. Daily, the office waited to see if the audit was completed. Most of the staff expected the audit to end soon. I, on the other hand, did not know what to expect. After previously speaking with the FBI and the insurance company, I realized that this situation was not to be taken lightly and would not be terminated easily.
As I had anticipated, the audit was not resolved so abruptly. The insurance company again applied pressure as auditors requested more chart information along with X-rays and perio chart narratives. These requests placed an extra burden upon the entire staff. It became even more apparent to me that this "updating of charts" that he led the office staff to believe was needed for the "routine" audit was even bringing questions to their minds as they reproduced mounds of requested X-rays.
My doctor's disposition became increasingly more agitated and very moody. His demeanor with the patients also began to change. The patients noticed my doctor's agitated nature and sensed friction in the office. They questioned me about insurance statements coming directly to them from their carrier with the fraud hotline number on them. I found it difficult to reply to these insurance issues and directed these questions to my doctor.
I continued to meet daily, plan strategy, and receive instructions from the FBI. My dental hygiene career was shifting to "dental spy-giene," as I worked jointly with the authorities to uncover facts. Weeks passed and I felt confident I was coming through with evidence that would take the investigation closer to an end. I felt uneasy, though, about what that end might be. The entire spectacle of working with the FBI and simultaneously providing hygiene care was mentally grueling.
During the final stages, the FBI asked me to come to their downtown office. I was allowed to review legal documents that put perspective to what I had been living through. Page after page, I read the formal allegations. Insurance fraud and the other legal infractions, if proven, would mean hefty fines and possible jail time for my dentist. The reality that an indictment was nearing set in for me. I began to fear what may happen to my dental reputation and worried about my safety once my doctor learned I was involved. The FBI assured me that they would protect me, and I felt safe believing that.
At work, I continued providing hygiene treatment, but realized my life and dental career were faltering. The FBI had what they needed from me to continue their investigation. They informed me that the next step would be to raid the office, seize the patient charts, and interrogate my doctor. It was difficult for me knowing that at any time the office could be raided and my friends on the staff might be out of jobs. Since the assistants in this office did not deal directly with entering treatment into the charts, the fraud issue was not one they would readily suspect. The raid would be a total surprise for my co-workers, and it would not be pleasant for me either. I suspected that the upcoming weeks would not be soon forgotten.
It is difficult to work anticipating a raid by the FBI. Fortunately, the FBI prepared me on what to expect. I wondered, though, how the other staff members would react.
One day, as I turned down the street where the office was located, I began to realize that the raid was already in progress. I could not believe my eyes and shock enveloped me, even though I had been briefed. The parking area was filled to capacity with FBI cars and a moving van. FBI agents were snapping pictures of the outside of the office. I apprehensively pulled into the parking lot and was flagged on by one of the investigators. Calmly, I parked in the adjacent lot, and got out of my car and reluctantly walked in.
The office was transformed. Mayhem filled the air. FBI investigators were walking around questioning the staff and taking photos of the operatories. I was escorted aside and asked simple questions such as my name, social security number, and if I knew why they were there. After my brief questioning, I approached the front office to find an investigator logging onto the computer, retrieving information from the system's hard drive.
The front office manager was calmly calling the patients to reschedule them. Rescheduling them for when I did not know.
After not immediately locating the doctor in the front office, I realized that he was in his private office with two investigators. I made my way to his office and timidly placed my ear to the closed door to listen. I could faintly hear what was transpiring. The doctor sounded as though he was unaware of any billing inconsistencies and was denying ever altering the charts.
The FBI agents continued to press him for a possible confession. I felt sick to my stomach and covered my mouth as I shook my head in disbelief that he was denying everything. I don't know what I thought was going to ensue. Of course, he would deny all of the allegations. I heard them also interrogate him about his billing techniques. Then, to my disbelief, he began to somewhat agree with them. As far as I knew, my doctor had not received any counsel from a lawyer as of yet.
I also remembered from my risk-management seminar that the malpractice insurance carrier wished to be alerted if possible infractions were occurring. I do not know if my dentist ever sought their direction either in the ongoing audit. I meandered about the office for some time absorbing what was taking place. Being in the office now felt like a scene from a movie — only I was a part of this drama.
I had to catch my breath or at least get some fresh air. As I stepped outside, I witnessed the files, place neatly in boxes, being carted away into a moving van. I was becoming increasingly ill as I played over in my thoughts that I was a part of this fiasco.
I boldly stepped back into the office and observed a casual conversation between the front-office manger and a patient on the phone. I thought it quite bizarre that the raid had not in the least bit put a damper on her day. I was puzzled that she was not flustered about the situation and wondered how she could remain so calm. After all, the FBI was toting away the patient charts and taking precious information from the computer hard drive. This was too much for me to comprehend. I told the office manager that I needed to speak with the doctor before I left.
The next conversation I had was with my dentist in the parking lot. He was not in a panic state as I had expected to find him in. He humbly assured me that I had done nothing wrong and that I had nothing to worry about. Additionally, he revealed to me some of what the FBI had questioned him about. The FBI told him they had recordings that could implicate him in fraud. My stomach quickly tightened as he continued. Surely, the FBI did not disclose so soon that I had been involved. As I turned my head away, I caught sight of the FBI continuing to load charts into the van. I could not have direct eye contact with my doctor for fear he would see my inner struggle. By now, I felt my dentist could tell that this dilemma was getting the best of me.
He casually stated that he might do a little jail time or pay some fines if the auditors uncovered damaging information. He acted as though it still was not a big deal. I glanced toward the office window as I heard a FBI agent say that they needed to talk again with the doctor. This broke up our conversation, and I proceeded to go back into the office to gather my belongings. I took my license off the wall and took one last look at the operatory where I had spent so much of my time. Mixed emotions raced through my mind. Saddened as I was, I would be glad to get on with my career. I would not return to this office. I left the turmoil behind me that day and drove away with a clear conscience.
Several weeks passed. By now, I knew my former colleagues would have an idea that I might have been embroiled in the case in some aspect. Because I departed so abruptly, they became suspicious of my involvement. Furthermore, they felt I left the office rather hastily and wondered why I abandoned them before anything was proven. Of course, to me, it already was confirmed. My ethical bond was forever broken there and not to be repaired.
To my surprise, I learned that the office remained open even after the raid. The staff started new records on everyone with the hopes that they would soon retrieve the real charts from the FBI. If patients noticed the "empty" filing cabinets, they were informed that chart maintenance was underway. The office continued to function with the hiring of temporary hygienists. The doctor also was called upon to perform prophys in addition to rendering dental services. Eventually, some of the other staff members left, taking assisting positions elsewhere. The office staff continued to dwindle.
The doctor's health came into question as he continued to function under the stressful load. He began to steadily smoke cigarettes and aggravated a pre-existing asthma condition. He had reached upper middle age and had talked prior to the insurance investigation of retirement. In the back of my mind, I believed the outcome of the entire scenario would be just that. He would stop practicing dentistry and begin his retirement.
About a month had elapsed since the FBI raid. I periodically spoke with the FBI to see how the investigation was progressing. It can be an unwanted realization when your charts, which you made entries into, are being evaluated for accuracy by the FBI. I felt very comfortable with my entries, so I dispelled any ideas that I made any intentional errors. The FBI assured me that they had what they needed to take the investigation further and seemed satisfied.
I quickly obtained a new dental hygiene position. My new job continued to prioritize my thinking, yet I wondered about my besmirched dental past. I slowly began regaining my enthusiasm for the dental field as I began the rebuilding process. Then the unexpected happened. I received a distressing call from a past co-worker that informed me that my former employer had unexpectedly past away.
Total disbelief overtook me, and, at first, I found it hard to believe. How could this happen? Had the stress been too much to handle? In a half-dazed state of mind, I immediately contacted the FBI agent who had been handling the case. I had to find out if he knew what had happened and discovered he hadn't learned of my doctor's ill-fated death. He listened in disbelief as I fumbled for the right words to express what had tragically happened. His soothing words calmed me. He stated that he would check into it and get back with me. Indeed, the doctor had a fatal cardiac arrest and had passed away. My involvement with the FBI, on this case, drew to a solemn close.
I reflect back on the events that led up to the calamitous end. I realize now that there was a breakdown in communications between the dentist and myself. My professional integrity with this dental practice was greatly challenged and unwisely undervalued. I do not regret my involvement in the case, but I do wish it had a different — and better — ending.
Karen Kaiser, RDH, is still practicing and can be contacted at [email protected]