Fraud or confusion?

April 1, 1999
Changes are taking place constantly in the insurance world. Keeeping up with them all can be enough to drive a normal and healthy psyche completely mad. There is so much confusion on recent emerging policies - mainly in the HMO arena - that it is virtually impossible to understand all of the procedural implications.

The insurance nightmare constantly threatens to unravel our professionalism.

Jerilyn Hanson, RDH, BS, MBA

Changes are taking place constantly in the insurance world. Keeeping up with them all can be enough to drive a normal and healthy psyche completely mad. There is so much confusion on recent emerging policies - mainly in the HMO arena - that it is virtually impossible to understand all of the procedural implications.

Unnerving and aggravating certainly describe dental insurance claims, policies, and procedures. You would have to be an expert on all insurance-company plans to keep up with the changes and diversity of coding procedures. How can the dental practitioner keep up with all of the changes and avoid filing fraudulent claims? Unfortunately, staying current is a feat that is difficult at best. Most practitioners have, at one time or another, unknowingly filed a fraudulent claim. The claims are filled out based on the advice of insurance-company representatives, and the assumption is that the information provided is true and accurate. Sadly, the information often is just the opposite - inaccurate - and provides the grounds for investigating the dental office on fraud charges.

The penalty for filing a fraudulent claim is quite severe, often resulting in a one- to five-year suspension of the hygienist`s license, as well as very steep monetary fines and probation. Although very few dentists ever deal directly with insurance claims, they are legally liable for any fraudulent billing that takes place by any employee in their practice. Hygienists can and are held liable, as well, when fraudulent billing has taken place for hygiene procedures.

A fact that many dental practices are completely unaware of is that most insurance companies do not fall under any of the same liability guidelines that the dentist or hygienist does. In other words, it doesn`t matter if a representative of the dental-insurance company gives the dental office false and inaccurate information. The insurer is not held accountable if fraudulent billing occurs as a direct result of information a company representative provides.

Most dental insurers fall under the category of third-party plans. This means that they do not have to follow the guidelines that government-regulated insurance companies do. Another disturbing fact about third-party insurance companies is that they can say anything they want to their clients ... who also happen to be our patients! Recently, our office actually had an insurance company tell one of our patients that the fee charged for the procedure performed was way too high! Fees too high? If that patient only knew that he had a policy with randomly-decided benefits! Two patients can have the exact same premium with the same insurance company, but completely different benefits. So who really is ripping off the patient? Try telling that to a patient who has just been told that the dental office he or she is going to is charging too much.

The majority of misbillings apparently occur because of inappropriate training and industry-wide confusion over proper billing codes. Accurate coding information is very difficult to access. Many of the codes that offices are required to use can be interpreted in different ways. It would be up to an investigator to decide whether or not you both agreed on your interpretation of the billing code. There are no formal certification requirements or comprehensive training programs available to help employees get the information they need to bill properly. Absurdly, staff members are given a huge responsibility with absolutely no training. At the same time, dentists are susceptible to what is referred to as "vicarious liability," which means that they are responsible for ensuring that all business staff members receive the training and skills necessary to do their respective jobs.

Undoubtedly, insurance companies need to take some of the responsibility for much of the confusion. But dental offices need to realize that research is necessary if they have questions about the proper use of billing codes. Research is the key to avoiding billing with false and inaccurate information. Do not take the information provided by the insurance rep on the telephone as being factual and written in stone, because it frequently is not.

A significant amount of confusion is caused by coding for periodontal procedures. Recently, a patient requested - at the advice of her insurance representative - that our office maximize her benefits by alternating the 04910 periodontal-maintenance code with the 0110 adult-prophy code for her three-month, periodontal-maintenance visits.

If your office is providing this "benefit" to patients on the advice of an insurance representative, stop! This absolutely is considered fraudulent by an insurance investigator, and the dentist can be and often is held accountable for such billing practices.

To avoid billing fraudulently, the simplest advice is to use the billing code for the exact procedure being performed. If you are providing service for periodontal maintenance, then bill Code 04910 for periodontal maintenance, even though the insurance company will allow payment for this code only twice per year. Let the insurance company adjust to a payable code if it chooses to do so.

Insurance companies are getting increasingly more ridiculous with their arbitrary decisions on what is a payable procedure and how much their portion of payment will be on a particular procedure. Periodontal procedures often are a target of benefit cuts. Apparently, the insurance companies would rather wait until the patient needs expensive bridges and other appliances before providing benefits. So many questions exist in the area of billing for periodontics that it can make your head spin:

- Can I bill an exam at the periodontal maintenance appointment?

- Will the insurance pay for the 4355 code for periodontal full-mouth debridement?

- Should I bill for a prophy if I already have used the 4355 code?

- Will the insurance company pay for root-planing if the procedure was done one year ago, but the patient needs it again?

The list goes on and on.

The next time you find yourself wondering if the insurance company will pay for a patient`s procedure, let it go. The very same patient that is asking you to fudge on the billing codes to maximize his or her benefits is the same one that would turn you in for fraud.

The Golden Rule always applies: "Do unto others as you would have them do unto you." You will never be a hero and wonderful to everybody. The big secret is finally out - people can sometimes be difficult! Now, there`s a revelation!

Jerilyn Hanson has spent more than 13 years as a dental hygienist and dental-hygiene educator. Currently, she is a practice management consultant and works part time in a dental office to stay current on hands-on dental procedures. She can be reached by phone at (888) 805-8634 or e-mail at [email protected].

Avoiding the tangled web of fraud

What can we do to protect ourselves from the confusion of the insurance nightmare and how can we avoid unintentional fraudulent billing practices? Here are six suggestions:

- Stay updated on current billing codes and procedures. Take the responsibility to enroll your office in insurance workshops and seminars. Since training in this area is not required, it is up to professionals to realize its importance and to seek out training.

- Make sure your office provides comprehensive information on procedures for billing and charting. You can never write too many chart notes and document too much information. Trust me - don`t let inadequate chart notes and periodontal charting be the reason for insurance-fraud investigators to place you on probation. Be sure your entire office is updated on all charting procedures. Send in the periodontal documentation with the claim for the procedure, because more insurance companies are requiring this prior to paying for the service. Of course, it is well known that this is just another stall tactic by insurance companies.

- Subscribe to industry newsletters or publications that offer current information on insurance-billing codes and procedures. Our office subscribes to Insurance Solutions, published by Northwest Dental Support. The telephone number is (425) 222-3593; fax: (425) 222-3594.

- Never, never, never allow a patient to pressure you into changing and/or manipulating billing codes. We all want to be the good guy, but the possibility of losing your professional license and huge fines should be reason enough to avoid this temptation.

- Remember why we are all in this profession: to provide the best possible care for our patients. Do not let insurance companies dictate how you diagnose and treat your patients. The best thing you can do to avoid doing this is to get into the habit of continuously reminding patients that the insurance company is the bad guy and not looking out for their best interests. I would recommend showing patients articles on insurance issues. Let them know just how ridiculous the insurance industry can be about paying benefits. At our office, we actually have made copies of two different plans from the same insurance provider for two of our patients. Both patients pay the same premium, but their benefits are entirely different. This helps to show patients just how arbitrary plans can be.

- More importantly, practice with high integrity and ethics. Always offer patients the best possible treatment options available. If you do these three things, you will be a winner in the eyes of both your patients and your colleagues.