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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 to commercial insurance and Medicaid payors.

Claims forms require a lot of information, such as:

·      Patient name/identifiers

·      Coverage information

·      NPI of billing provider

·      NPI of treating provider (may or may not be the same as billing provider)

·      Date of Service

·      Procedures reported by CDT code

The certification section of the claim forms states, “I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed and that the fees submitted are the actual fees I have charged and intend to collect for those procedures.”

It is presumed that when someone causes a claim to be submitted for reimbursement, it is done intentionally and with expectation the information presented is true, accurate and correct. As such, it is also presumed that any misinformation, errors, omissions, mistakes are purposeful and that reimbursement for said claims is done under false pretenses (false claims).

Whether actually intentional or by mistake – misinformation is treated like fraud and has consequences as such.

The question is, when the payor discovers the errors by way of auditing your records, will they pursue the matter criminally or civilly?

No two situations are the same. I have seen payors’ responses each way and both ways. 

Common claim forms issues are:

·      Fail to identify actual treating provider (usually associates or non-credentialed provider)

·      Incorrect tooth/teeth #s

·      Incorrect tooth/teeth surfaces

·      Procedure indicated in claim form, but not actually provided

·      Procedure indicated on claim form, but not documented in clinical note

·      Incorrect procedure code indicated

·      Procedure coded is not the procedure actually provided

·      Wrong date of service

This is not an exhaustive list!

These claims submitted result in claims paid or claims denied. Dentists are liable for claims submitted whether they are paid or not, whether they have actual knowledge of the claims submitted on their behalf or not, whether they are Medicaid or not.

The bottom line is clear: dentists are responsible for the use/misuse of their NPI and other professional credentials. Ignorance is no excuse. Dentists, you simply must be in the know about what and how your credentials are used and by whom.

Whether you are an owner-dentist or are an associate in either a private or corporate practice, you need to review the claims submitted on your behalf to ensure they are true, accurate and correct.

One way to address potential coding, documentation and billing concerns is to BOLO (Be On the Look Out) for the common items outlined above.

If you see something – say something!

If it falls on deaf ears, seek the experience of a competent healthcare attorney to limit your liability and get ahead of the situation.

You are either part of the problem or part of the solution. I’m sorry to sound so cliché, but in this case it’s true.

Get in Touch

Phone 817-755-0035

email: toothcop@dentalcompliance.com