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Sometimes when you mess up – and that mess up involves Medicare, Medicaid, or funds from another government healthcare program – not only do you have to fix the mess, but you may also have to go back and make amends to limit your liability and hedge against civil and/or criminal prosecution later.

Hospitals do it.

Physician groups do it.

Ambulance providers do it.

Home health does it.

What?

Get busted for coding, documentation, and billing problems.

The federal government developed the Self-Disclosure Protocol (“SDP”) for healthcare providers to be able to bring themselves forward to the government in a way that says, “we know we messed up, and we would like to fix it without the government throwing the book at us”.

This is an actual protocol.

While the intent is goodwill on both parties, it doesn’t preclude the government’s ability to pursue criminal prosecution if the self-report is merely to circumvent prosecution (which is rare).

Implementation of the SDP should be done with the assistance of a healthcare attorney experienced in self-reporting.

Going to the government to turn yourself in to proactively address a series of errors or mistakes made by you or a member of your dental team, as it relates to billing to government-funded healthcare programs, can be a life-saver.

Why the heck would I ever do that, you ask?

Simple!

You coded something incorrectly (serially)…

Your staff selected the wrong treating provider from a drop-down box in your dental billing software (serially) …

You billed for, say fluoride treatment provided by your hygienist, but find her clinical notes over the course of months (or years) do not actually indicate she provided fluoride treatment.  Your claims history shows you billed for and were reimbursed for it. Are you going to have her correct EVERY clinical note? What if she does not remember whether or not she actually provided it?

Perhaps you have a series of claims that indicate incorrect dates of service…

You had an employee in your practice who is excluded from working in a Medicaid practice… You checked exclusion records prior to his/her hire, but not since. You recently found out your employee has been excluded for 4 years, which effectively taints all your Medicaid claims, making every claim you submitted to Medicaid for the last 4 years false claims to the government a simple oversight, a mistake.

This is not an exhaustive list of things a dentist might self-report.

You have two choices: 1) Do nothing, hold your breath, and hope you don’t get busted. OR. 2) Be proactive and implement the SDP.

There are consequences for each.

First, the good-ish news.

Say you implement SDP and self-report. The government can require repayment up to double the amount paid to you under the Civil Monetary Penalties Rule.

Under the “wait and see” approach, if you wait and get found out, you get busted. You’re looking at triple repayment plus penalties up to $21,936 PER CLAIM.

Neither is an exciting option, but at the end of the day your choice is to write one of two checks. Which would you rather write?

1.     Double repayment or

2.     Triple repayment and $21,936 for each claim!

Always discuss these situations before deciding whether or not to self-report.

I am not an attorney, and nothing in this article should be construed as legal advice.

For more information on the Self-Disclosure Protocol go to the federal Office of the Inspector General (OIG) website: https://oig.hhs.gov/compliance/self-disclosure-info/index.asp

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