News — Recordkeeping

More practices today are use electronic dental records. There are certainly pros and cons of doing so, which is beyond the scope of this blog post. What is important is that the software used today allows providers to template their notes, which are often necessarily-detailed. The problem with using templates, especially those with pre-populated answers are whether the answers accurately reflect the patient presentation, diagnostic test results (i.e. x-rays), the dentist’s findings/recommendations, and (ultimately) treatments provided. If yes, great! If no, oh no!

Physician practices and hospitals routinely audit for compliance, risk management, revenue cycle and quality of care issues.  They don’t necessarily like it, but they’ve settled into the routine of doing it to minimize their losses in the ever-increasing fight for dollars between providers and payors. Sadly, few dental practices audit patient records. A lot can be learned from auditing including identification of incomplete or inadequate documentation and/or paperwork, missed billing opportunities, issues that can result in recoupments (even criminal prosecution), and a host of other issues.   A dentist’s work is only as good as his records. It is said...

When a dentist or DSO (or any other healthcare entity) get busted for Fraud, Waste or Abuse (FWA) issues the government may decline criminal prosecution in favor of a civil settlement known as a Corporate Integrity Agreement (CIA). There is much to unpack about CIAs. Here is what I know: Corporate Integrity Agreements have become a favorite tool of the federal government. You can gain valuable insights on how to protect your practice by reading CIAs (and other government enforcement actions). Every CIA includes requirements that the organization incorporate the OIG’s seven core elements (8 if you're a New Yorker)...

As you can see from the title, today’s discussion centers on dental claims, which are utilized to seek reimbursement for services rendered.    Under the HIPAA Transactions and Codes Sets Rule, dentists are required to use a designated code set for billing purposes. These codes are the ADA Current Dental Terminology.   Under the HIPAA Unique Identifier Rule, dentists and physicians are required to obtain and use a National Provider Identification (NPI) number for professional purposes, which is like a professional social security number.   The ADA established a uniform claim submission form which is commonly used for claims submission...

As healthcare practitioners, dentists may be the only doctor some of your patients may see. This is a great opportunity for you to connect with your patients about what's important to them. Written review of medical history, like treatment consent, can seldom be over-documented. This is another issue where state boards may differ.As a general rule, I suggest you and your staff update patient medical histories prior to performing any clinical procedure. This also applies to orthodontists, who often believe they are exempted because they don't perform invasive procedures. Keeping updated medical histories can help prevent terrible medical tragedies. Know your patients' health...