bsdfshrah

Monday, November 24, 2014

Myths, Rumors, and Bald Faced Lies- Truths Revealed about the DSO Industry

Myths, Rumors, and Bald Faced Lies- Truths Revealed about the DSO Industry

By: Michael W. Davis, DDS

There exists a great deal of misinformation, as well as intentional misrepresentations, within the dental service organization (DSO) industry. Much, if not most of this of this, is fostered by the DSO industry itself.

Historically in healthcare, dentists were held to ethical and legal standards within the doctor/patient relationship (legal contract) always placing their patient’s interest, above all other interests. Court rulings have determined that because of a doctor’s expert knowledge, which is not easily accessible to the general public, the patient is at a distinct disadvantage within this contract agreement. Obviously, the delivery of healthcare services is a very different matter, than the buying and selling of widgets.

A corporate third party, the DSO, may enter into this contract agreement (doctor/patient relationship). This is usually without the knowledge or consent of the patient. Such an action may invalidate as unlawful, the doctor/patient relationship. (Please reference Fifth Circuit Ruling: 07-30430.) DSOs, which utilize bonus systems and production quotas for professional providers, are engaging in the unlicensed and unlawful practice of dentistry. Such corporate violators are subject to the same regulatory sanctions and disciplinary actions, as individual violators. Unfortunately, too few government regulators have advanced past their current ineptitude and corruption. This must change.

“At XYZ Dental, we allow you to focus on what you do best; provide excellent dental care for patients. We take care of all the rest.” is a common corporate dentist-recruiting message. Even the provider contracts include a proviso waiver that only licensed dentists provide dental care. Unfortunately, contract verbiage is far from the reality.

Unlicensed corporate managers, not doctors, very often make clinical decisions effecting direct patient care. This may include the quantity and quality of dental supplies for a dental clinic. It may include a very limited selection of utilization of dental laboratories, many of which are undisclosed offshore dental lab sweatshops. Unlicensed corporate clinic managers, who are not under any doctor’s supervision, may be utilizing arm-twisting sales techniques, to get patients to sign on for financing of unnecessary dental care. Similar arm-twisting may be used on doctors and hygienists, to increase clinic profits, by selling unneeded dental treatments to their patients.

Hygienists, who lawfully must be working under the direction and supervision of a duly licensed doctor, are today working for whomever writes their paycheck. Periodontal probing measurements are invented, to generate additional cases of unnecessary scaling and root planing (deep cleaning). Sulcular antibiotic therapy is sold to patients, even before assessment of results, to initial therapy of scaling and root planing. Adult cleaning visits are often restricted to 20-30 minutes, which nearly always leaves excessive disease-causing agents. In fact, often unlicensed dental assistants are providing hygiene services.

Generation of corporate profits trumps the interests of patients. Any dental professional employee who dares question the corporate model will soon be out the door. After all, a corporation’s first fiduciary responsibility is to generate maximal returns for shareholders. The interests of patients never enter the picture.

Upper management in the DSO industry will often argue, that numbers of non-corporate doctors are engaging in the same or similar patient abuses, within their smaller businesses. And, this justifies their grand scale abuses, how? It’s the old lame failed argument, of justifying bad behavior, with other examples of bad behavior. Reality: dental regulatory boards have reported a far greater percentage of statute violations originating from corporate dentistry, than from smaller doctor-controlled practices.

Another DSO fallacy often relates to doctor financial compensation. Verbally, their management and doctor-recruiters advise dentists of compensation, clearly based on a percentage of the doctor’s clinical production and/or hourly wage. Yet, the complex legalese of the employment contract, seemingly tells another story. These contracts are often so complicated, only a law firm concurrently expert in business law, contract law, and finance could hope to decipher the maze of legal verbiage.

Fortunately, any American Dental Association (ADA) member can have these contracts reviewed, as a benefit of membership. Few recent grads take advantage, as they not only lack finances to hire an appropriate attorney for contract review, but also are often not ADA members.

Wednesday, November 19, 2014

Mechanisms of Dental X-ray Scams

clip_image002By: Michael W Davis, DDS

Dr. Michael W. Davis maintains a private general practice in Santa Fe, NM. He chairs the Santa Fe District Dental Society Peer-Review Committee. Dr. Davis is active in dental care for disadvantaged citizens. His publications are on ethical issues within the dental profession, as well as numbers of clinical research papers.

 

November 19, 2014

Frequently, the media, non-dentist investigators, and the public ask me, the methods and means of swindles played out with dental x-rays. Most incorrectly assume, that patients are simply given excess numbers of unnecessary radiographs, to increase billing statements.

Both the insurance industry and Medicaid generally pay 100%, for the costs associated with dental x-rays. These third party payers have limits on the frequency and types of radiographs, which they will cover for benefits under their contracts with dental providers. Most dental insurance carriers have computer-generated algorithms, which are triggered when excessive x-rays are taken. Moneys are then not paid out, or immediately recuperated, in the next insurance payment cycle.

Medicaid oversight is generally more lax. However, there is a very real risk with dental x-ray over-billing, that this will be caught by Medicaid oversight mechanisms, even as incompetent as they usually are. Generally, large sums of Medicaid over-payments are generated, and regulators chase down very large sums, well after the fact (“Pay-&-Chase”). Often, only pennies on the dollars are returned to taxpayers. However, it represents a scam with some element of downside risk. As dental Medicaid fraud has become an accepted business model with in the dental industry, swindlers desire to minimize or eliminate regulatory risk.

Today, large interstate corporate dental providers retain former state and federal dental investigators. These corporate dental providers, which are usually beneficially owned by the private equity investment industry (Wall Street parties), have a good idea of which forms of fraud will be potentially investigated, and which methods of fraud will fly under the radar. Regardless, the corporate beneficial owners always retain licensed doctors acting as nominee owners (sham-owners), to assume any potential regulatory liabilities.

Most commonly, we observe the following forms of dental scams with dental radiographs.

Unbundling of X-ray Services

The American Dental Association (ADA) has established a clinical coding system called, “Common Dental Terminology” (CDT). Numerical codes are designated for nearly every possible dental service. This system is updated annually. Every insurance carrier and Medicaid will establish fees for each dental service, for which coverage is provided under their program. One such dental service is called a “complete series of radiographs”, which has a set fee, and CDT code number.

The scam involves taking a fair number of x-rays on a patient, and charging out for these multiple individual radiographs with multiple different CDT codes, to a sum greater than the fee, for a complete series of radiographs. This dishonest billing is termed unbundling.

Upcoding of X-Ray Services

Many pediatric dental patients, especially those with short attention spans, and who physically move about frequently, are unable to sit still long enough for a panographic x-ray (very large radiograph, approximately the size of a small loaf of bread). Thus, two occlusal radiographs (these approximate the size of a playing card) are often substituted. Cheats will frequently take a standard sized periapical x-ray (approximately the size of a domino), and turn it 90-degrees, and misrepresent that radiographic service, as an occlusal x-ray, and not a periapical radiograph, which it truly is.

This scam is usually played out, when the CDT code fee for an occlusal radiograph is more than a periapical radiograph. Since the only way to catch this fraud is with a physical auditing of the patient records, it’s easy to get away with. 

Non-Diagnostic Quality X-rays

When dental providers bill for x-ray services, they are assumed to bill for diagnostic quality x-rays. Any reasonably qualified doctor should be able to view the radiographs, and use that data to assist in generation of a patient treatment plan with their total examination. A patient treatment plan is generally an essential and required part of any patient record. Further services (fillings, crowns, extractions, root canal therapies, etc.) provided to a patient are based upon the patient treatment plan, and diagnostic quality x-rays.

When a doctor utilizes non-diagnostic quality radiographs (x-rays with processing errors and distortions, incorrectly positioned x-rays, etc.) to generate a patient treatment plan and provide clinical services, the patient and third party payer may be cheated. Not only is it unlawful to bill for the non-diagnostic quality radiographs, but also dental services delivered based upon these x-rays may represent malpractice and/or fraud.

Again, this form of malpractice/fraud is difficult to catch, without an on-site patient record audit, or physical examination of the records. Once patient records are subpoenaed for a civil or criminal legal action, a Medicaid audit, or a state dental board administrative law complaint, we commonly see non-diagnostic quality x-rays to be the unreasonable standard-of-care, for an unfortunate subset of practitioners. Too frequently, we see very extensive patient care (multiple steel crowns, pulpotomies a/k/a baby root canals, extractions, etc.) based on non-diagnostic x-rays and a very sketchy patient treatment plan.

Missing X-Rays

This too often comes down to three possible situations, none of which are good. The doctor claims the x-rays have gone missing. Patient records are assigned a responsible custodian for ownership. In most states, this is a licensed doctor. In other states, a corporate dental service organization may be assigned ownership, and treating doctors have specific and limited rights to access patient records (Again, a dangerous situation for patient rights. Also, potential for a corporate dental provider, to blackmail employee dentists’ testimony, when the corporate model of dental practice is outside the norms of the dental industry, involving fraud as an overall business model. “If you talk doctor, we’ll throw you under the bus, just like we did with the current defendant.”).

Missing records, inclusive of dental x-rays, does not bode well for defendants in civil or criminal malpractice or fraud cases. A judge will most often make a ruling, which casts a negative inference, upon subpoenaed and non-produced discovery material. Records not produced are deemed to negatively impugn defendant(s). 

The third possibility is that the dental radiographs never existed, in the first place. Yes, billing statements were generated for dental x-rays, but these services were not provided. Extensive treatment plans and other dental services were provided, all without supportive dental x-rays. A good question for plaintiff’s attorney to ask a defendant/doctor at deposition may be, “Are you related to Superman, because you must have x-ray vision?”.

 Conclusion
Scams involving dental x-rays may be somewhat more complex, than many assume. Implications for malpractice and/or fraud go far beyond the radiographs themselves. Auditors, investigators, policy makers, legislators, leaders in organized dentistry, and the public must be alerted, to these common frauds played out in the dental industry. The crooks aren’t simply a handful of small-time dentist bunco operators. These swindles go directly to the heart of unregulated corporate America, which beneficially owns many of these disturbing dental clinics. The public interest must supersede the interests of all others, when it comes to our nation’s healthcare.


Wednesday, November 05, 2014

Nearly 100 Indiana dentists found to have questionable billing in HHS Report

Capture

 

Feds: 95 Indiana dental providers have questionable billing

Marisa Kwiatkowski, marisa.kwiatkowski@indystar.com 7:01 a.m. EST November 5, 2014

A federal report released Wednesday found questionable billing practices by 94 dentists and one oral surgeon who treat Indiana children on Medicaid.

Those providers received about $30.5 million in government funds for pediatric dental services, according to the report by the U.S. Department of Health and Human Services’ Office of Inspector General.

Federal officials did not cite specific dentists or clinics in the report, but said the findings demonstrate the need for improved oversight of pediatric dental services paid by Medicaid in Indiana.

Officials studied claims paid by Medicaid in 2012 for such dental services and focused on those who served more than 50 children.

Two-thirds of the dentists cited in the report for questionable billing worked for four dental chains. Three of those chains have been the target of state and federal investigations, according to the report.

Read the entire story here

 

 

HHS Report - Indiana Questionable Pediatric Dental Mediciad Billing November 2014