Transcript Stay out of Jail

RAISING THE
REIMBURSEMENT
ROOF
WHILE REDUCING REGULATORY RISK
[email protected]
www.royshelburne.com
276-346-3863
1
ROY’S DISCLAIMER:
 I am not an attorney
 The comments and observations made in this presentation
are not to be taken as legal advice
 The material shared is based on my understanding of best
practices
 The information I share is my opinion and is based on my
experience and subsequent research
 I cannot promise that implementing the systems I
recommend will ultimately prevent legal action
TODAY'S LEGAL ENVIRONMENT
 Malpractice Claims
 Insurance companies have become much more
concerned with identifying, penalizing, and
prosecuting healthcare fraud
 Board of Dentistry Actions:
◦ Most citations are related to record keeping
LEGAL DEFINITION OF “INTENT”
Blind Disregard
Who is ultimately responsible?
INSURANCE
 Conventional (Indemnity)
 PPO’s
 HMO’s
 Direct Reimbursement
 Discount Plans
“I hereby certify that the procedures as indicated by
date are in progress (for procedure that require
multiple visits) or have been completed”
ADA CLAIMS FORM LANGUAGE
DISCOUNTED FEE FOR PRE-PAYMENT
TREATMENT PLAN
$1,000
5% CASH DISCOUNT
$ 950
What goes on the form? $1,000 or $950?
DISCLOSING CO-PAY FORGIVENESS
 All states prohibit co-pay forgiveness without third-party
notification.
 Virtually all PPO’s prohibit co-pay forgiveness!
 If you “forgive” the co-pay in an isolated situation, the remarks
section should read:
“The patient is not participating in the cost of treatment.”
Note: Always disclose fee forgiveness to third-party.
STATE AND ERISA PLANS
Insurance (only applies to “insured plans” under State Insurance
Commissioner, not self-funded plans of large employers –ERISA)
 Employee Retirement Income Security Act of 1974 (ERISA)
ERISA TYPE PLAN

Employment Retirement Income Securities Act (ERISA) – a Federal
Law.

Controls accident and health plans and retirement plans of selfemployed and employer’s benefit plans.

Self-funded, not insured plans, are under ERISA. Self-funded plans
are often larger employers.

Can fee cap for non-covered procedures.
PROMPT PAYMENT LAWS

Passed by all states

“Clean Claim” is one with all fields completed and complies with
payer’s filing (published) requirements.

“Clean Claims” must be paid in 30/60 days, according to state law.

Prompt Payment Laws do not apply to self-funded (ERISA) plans.

Some PPO self-funded contracts spell out the prompt payment
policy, however.
BILLING FOR “OPTIONAL SERVICES”
 Check with the carrier
 Discuss with the patient
 Signed agreement from the patient
 Use the correct corresponding code
 D_999 code
 Regular code
 Attach a copy of the agreement with the claim
“OPTIONAL SERVICES”
 Limitations on All Benefits - Optional Services that are more expensive
than the form of treatment customarily provided under accepted dental
practice standards are called “Optional Services”. Optional Services also
include the use of specialized techniques instead of standard
procedures. For example:
 a crown where a filling would restore the tooth;
 a precision denture/partial where a standard denture/partial could be used;
 an inlay/onlay instead of an amalgam restoration;
 a composite restoration instead of an amalgam restoration on posterior teeth.
 If you receive Optional Services, Benefits will be based on the lower
cost of the customary service or standard practice instead of the higher
cost of the Optional Service.You will be responsible for the difference
between the higher cost of the Optional Service and the lower cost of
the customary service or standard procedure.
RECORD KEEPING LAW AND RECORDS
RETENTION LAW
The ADA’s Recommendations
CAN YOU LEGALLY. . .

Charge different fees for different people?

Charge different fees for different plans?

Charge different fees for same procedure code?

Charge different fees for non-insurance patient versus PPO
Insurance patients?
WHAT DELTA TELLS THE PATIENT:
If the Dentist discounts, waives or rebates any
portion of the Enrollee Coinsurance to the
Enrollee, Delta Dental will be obligated to
provide as Benefits only the applicable
percentages of the Dentist’s fees reduced by
the amount of such fees that is discounted,
waived or rebated.
FEE REDUCTIONS
Discounting
Co-pay forgiveness laws
Ethical Considerations
PATIENT GIFTS FOR REFERRAL


Prohibited by many state’s law.
Prohibited by Medicaid or governmentfunded program.
CREDENTIALING
Name on the claim form as provider of service
FEES
In-network charges
Out of network charges
PPO CONTRACTS
Several pages only
Refers to “procession policy
manual”
Provide emergency care
PPO CONTRACTS
Agree to lower of PPO fee, or the
practices unrestricted fee
Agree to same clinical protocol
Agree to non-discriminatory patient
appointment times
PPO CONTRACTS
Agree to provide any and all
information requested
Agree to audit on premises
PPO CONTRACTS
Audit payback—if audited, associate must pay
back money in 90 days.
Agree to offset of payment in slow pay/disputes
Can terminate with 30/60 days
Malpractice requirements and limits
Contract can be modified unilaterally by
insurance company with 30/60 days’ notice
Upgrades to basic PPO covered services
AADC
Diagnostic Software
Continuous Audits
Standard Deviations
Chart Reviews
Fraud Flags
WHERE ARE YOU?
WHO GET AUDITED?
Those who participate with PPO’s
You have not choice. You must cooperate
Those who do not participate with PPO’s
You have a choice
Bear the consequences
AUDITS, WHAT TO EXPECT?
In network or out of network?
Audits are performed to determine:
That the procedure was performed
That the procedure was “medically
necessary”
That the procedure was not
cosmetic
AUDITS
 Audits are performed to determine:
 That the fee charged was the same fee charged to
non-insurance patients in similar circumstances
 That the clinical protocol for non-insurance patients
was the same clinical protocol for insurance patients
in similar circumstances
 That the procedure is not up-coded
 Example: A surgical extraction (D7210) is charged
instead of a routine extraction (D7140).
AUDITS
That the claim form was accurate
That the procedure was properly
represented by the current CDT 2013 code reported
Rights if non-participating
TOP CODES UNDER REVIEW
1. D4341, Periodontal scaling and root
planning, four or more teeth per
quadrant
TOP CODES UNDER REVIEW
2. D1110/D4910 on the same patient
TOP CODES UNDER REVIEW
3. D2950, Core build-up, including any pins
TOP CODES UNDER REVIEW
4.
D7210, Surgical removal of erupted
tooth requiring removal of bone
and/or section of tooth
TOP CODES UNDER REVIEW
5. D2391, Resin-based composite, one
surface posterior
TOP CODES UNDER REVIEW
6.
D2335, Resin-based composite, four
or more surfaces or involving incisal
angle (anterior)
TOP CODES UNDER REVIEW
6. X-rays…of any kind
TOP CODES UNDER REVIEW
7.
Impactions
SERVICES UNDER REPORTED:
D0180: Comprehensive Periodontal Evaluation –
New or Established Patient
 This procedure is indicated for patients showing signs or symptoms
of periodontal disease and for patients with risk factors such as
smoking or diabetes. It includes evaluation of periodontal
conditions, probing and charting, evaluation and recording of the
patients dental and medical history and general health assessment.
It may include the evaluation and recording of dental caries, missing
or unerupted teeth, restorations, occusal relationships and oral
cancer evaluation.
REATTACHMENT OF A TOOTH
FRAGMENT, INCISAL EDGE OR
CUSP
D2920
RESIN INFILTRATION OF INCIPIENT
SMOOTH SURFACE LESIONS
D2990
Placement of an infiltrating resin restoration for
strengthening, stabilizing and/or limiting the
progression of the lesion
D4341/D4342 AND D4910
Perio Scaling and Root Planing
Periodontal Maintenance
Do the math:
PERIODONTAL MEDICAMENT
CARRIER WITH PERIPHERAL SEAL –
LABORATORY PROCESSED
D5994: A custom fabricated, laboratory processed
carrier that covers the teethe an alveolar mucosa.
Used as a vehicle to deliver prescribed
medicaments for sustained contact with the gingiva,
alveolar mucosa, and into the periodontal sulcus or
pocket:
 Perio Protect™
PALLIATIVE: D9110
Palliative (Emergency) Treatment of Dental
Pain – Minor Procedure
This is typically reported on a “per visit” basis
for emergency treatment of dental pain
RECORD KEEPING
ABOUT RECORD-KEEPING - BE DEFENSIVE.
If it is not in the clinical record
1. It was not seen
2. It was not said
3. It was not heard
4. It didn’t need to be done
5. It wasn’t done
6. It doesn’t exist…from the legal perspective
CLINICAL RECORD AND THE CLAIM
 They should mirror one another
 The Clinical Record should record pertinent information and should justify
and support the treatment
 Evaluation
 X-rays
 What was observed that helped in the treatment planning process
 Anything “surprising”
PRIMARY-SECONDARY INSURANCE




Only determines the sequence of insurance billing.
Make no adjustment to patient’s account until after secondary
has paid.
Primary-secondary status does not determine the patient’s
responsibility. The patient’s responsibility is determined by the
lower of the contracted fee schedules.
Primary payer for a child is determined by which parent
whose birthday comes first in the calendar year. The birthday
rule can be overridden by a court order (Divorce Agreement).
COORDINATION OF BENEFITS
Write-offs – when to take them?
COB test
THE MOST COMMON FRAUDULENT
ACTS
 Billing for services, procedures, and/or supplies
that were never provided or performed.
 The deliberate performance of medically
unnecessary services for the purpose of financial
gain.
Source: National Health Care Anti-Fraud Association (www.nhcaa.org).
THE MOST COMMON FRAUDULENT
ACTS
 Intentionally misrepresenting any of the following,
for purposes of obtaining a payment—or a greater
payment—to which one is not entitled:
• The nature of services, procedures, and/or
supplies provided or performed
• The dates on which services and/or treatments
were rendered;
Source: National Health Care Anti-Fraud Association (www.nhcaa.org).
THE MOST COMMON FRAUDULENT
ACTS
•
The medical record of service, and/or treatment
provided
•
The condition treated or the diagnosis made;
•
The charges for services, procedures, and/or
supplies provided or performed;
•
The identity of the provider or the recipient of
services, procedures, and/or supplies.
Source: National Health Care Anti-Fraud Association (www.nhcaa.org).
MALPRACTICE CONSIDERATIONS
 Deviation from the standard of care
AND
 Injury
 Does “stuff” happen?
 Inform
 Handle the situation appropriately
FAILURE TO DIAGNOSE
An evaluation indicates that a diagnosis has been
established or that arrangement to determine the
diagnosis has been made:
Periodontal conditions
Oral lesions
PRESCRIPTION MONITORING PROGRAM:
WHAT DO WE DO NOW?
 Honest Assessment
 Meet with the team
 Determine where you are
 Decide where you want/need to be
 Develop a plan
 Set your standards
 You get what you accept, not what you expect
 Train
 Trust
 Review
Thank you!
423-552-6111
www.royshelburne.com
email: [email protected]