Everyone needs a compliance program tailored to the needs of their practice. Justin Withrow jumps in when a compliance program is absent and things go horribly wrong. Perhaps a client was employing an individual that's excluded from participation in the Federal Healthcare Program that should have been caught. 

There is a multitude of things that could happen that could have been prevented by a compliance program. In this episode of Talking with the Toothcop, we dissect the importance of exclusion monitoring, the basics of the false claims act, self-disclosure protocol, and much more.


The importance of exclusion monitoring 

Justin worked with a multi-location practice where the owner worked with walk-in and Medicaid clients frequently. He was doing criminal background checks and checking licenses with the dental board. But he didn’t know an exclusion list existed with the Federal Healthcare Program that could exclude providers from working with the Medicaid program. Unfortunately, one of his providers knew they were excluded and didn’t tell him. It resulted in a fraud investigation of his practice. He was looking at jail time for something that could easily have been avoided. 

It feels like science fiction but it’s the real deal. It’s as simple as running your licensed staff members’ names through a website. You need to know they’re authorized to work with your patients so you can get reimbursed for services rendered. If you don’t, they’ll take that money back—and then some. Justin dissects the basics of the false claims act and the fines you could be looking at if you were caught in this situation. Don’t miss it. 


The submission of “unclean” claims 

If you submit a claim for reimbursement by a provider who is excluded from a state Medicaid program, that claim is labeled as a false claim. Let’s say a practice employs someone who they knew was excluded and billed services as rendered by a credentialed provider. If it was determined the service was rendered by an excluded provider, that triggers a false claim. Any service rendered by an excluded provider and submitted for reimbursement to Medicaid is a false claim

If a provider has been excluded, that individual can’t have contact with any patient insured with Medicare or Medicaid. If they work on that patient that claim cannot be reimbursed. That’s why it is SO important to do exclusion checks. This applies to dental assistants, hygienists, and even administrative staff. Every member of your organization needs to be regularly run through exclusion databases. 


Defining self-disclosure protocol

A compliance program helps you identify improper practices (something coded incorrectly, overpayment, etc.), catch them, and self-disclose or clarify that you made a mistake. You can let the governmental agency know a mistake was made and correct the mistake. Usually, you’re given a certain time period—60 days—in which to self-disclose. The government knows mistakes happen. That’s why this protocol exists. 

If you’re in the general ballpark of 60 days, it’s usually fine. Even if you’re outside of the 60-day window, doing nothing is the wrong approach. You will get in trouble down the road. It’s always appropriate to rectify your mistakes when they’re identified. Just work with a professional to do it appropriately.  


What a compliance program must address

A compliance program must address the policies and procedures that an office uses to operate (i.e. OSHA, HIPAA, dental board regulations, state and federal regulations, etc.). You must properly and safely render care to patients while adhering to various laws of various agencies. It’s an all-encompassing document that dictates how you do everything in your practice. It’s who you are and how you operate. It has to be reflected in the day-to-day operation of your practice.  

People always say, “We’re too busy.” That’s NOT okay. It’s an excuse. These things can’t fall by the wayside. This has to be a staple of your business. There needs to be a compliance officer that is someone other than the dentist. They are your professional lifeguard. They stop the real cops from coming into play. If you’re “Too busy” it’s only a matter of time before you’re audited or investigated.

Outline of This Episode

  • [3:56] The importance of exclusion monitoring 
  • [6:30] The basics of the False Claims Act
  • [11:56] Defining self-disclosure protocol
  • [16:21] What a compliance program must address
  • [24:12] Managing the merger and acquisition process
  • [29:21] Possible reductions in fines and penalties
  • [31:44] How to connect with Justin Withrow

Resources & People Mentioned

Connect With Duane

Previous Article Next Article