Raising the Reimbursement Roof While Reducing Regulatory Risk

1. Raising the Reimbursement Roof While Reducing Regulatory Risk roy_shelburne@hotmail.com www.royshelburne.com 276-346-3863

2. 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

3. 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

4. Legal Definition of “Intent” • Blind Disregard • Who is ultimately responsible?

5. Insurance • Conventional (Indemnity) • PPO’s • HMO’s • Direct Reimbursement • Discount Plans

7. “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

8. Discounted Fee for Pre-payment What goes on the form? $1,000 or $950?

9. 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.

10. State and ERISA Plans • Insurance (only applies to “insured plans” under State Insurance Commissioner, not self-funded plans of large employers –ERISA) • EmployeeRetirement Income Security Act of 1974 (ERISA)

11. ERISA Type Plan • Employment Retirement Income Securities Act (ERISA) – a Federal Law. • Controls accident and health plans and retirement plans of self-employed 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.

12. 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 donot apply to self-funded (ERISA) plans. • Some PPO self-funded contracts spell out the prompt payment policy, however.

13. 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

14. “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.

15. Record keeping law and records retention law • The ADA’s Recommendations

19. 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?

20. 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.

21. Fee Reductions • Discounting • Co-pay forgiveness laws • Ethical Considerations

22. Patient Gifts for Referral • Prohibited by many state’s law. • Prohibited by Medicaid or government-funded program.

23. Credentialing • Name on the claim form as provider of service

24. Fees • In-network charges • Out of network charges

25. PPO Contracts • Several pages only • Refers to “procession policy manual” • Provide emergency care

26. 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

27. PPO contracts • Agree to provide any and all information requested • Agree to audit on premises

28. 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

29. AADC Diagnostic Software Continuous Audits Standard Deviations Chart Reviews Fraud Flags

30. Where are you?

31. 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

32. 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

33. 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).

34. Audits • That the claim form was accurate • That the procedure was properly represented by the current CDT -2013 code reported • Rights if non-participating

35. Top Codes Under Review • D4341, Periodontal scaling and root planning, four or more teeth per quadrant

36. Top Codes Under Review • D1110/D4910 on the same patient

37. Top Codes Under Review • D2950, Core build-up, including any pins

38. Top Codes Under Review • D7210, Surgical removal of erupted tooth requiring removal of bone and/or section of tooth

39. Top Codes Under Review • D2391, Resin-based composite, one surface posterior

40. Top Codes Under Review • D2335, Resin-based composite, four or more surfaces or involving incisal angle (anterior)

41. Top Codes Under Review • X-rays…of any kind

42. Top Codes Under Review • Impactions

43. 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.

44. Reattachment of a tooth fragment, Incisal edge or cusp • D2920

45. 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

46. D4341/D4342 and D4910 • Perio Scaling and Root Planing • Periodontal Maintenance • Do the math:

47. 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™

48. 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

49. Record KeepingAbout record-keeping - be defensive. • If it is not in the clinical record • It was not seen • It was not said • It was not heard • It didn’t need to be done • It wasn’t done • It doesn’t exist…from the legal perspective

50. 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”