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Avoid these potentially fraudulent teledentistry mistakes

Dec. 2, 2021
Many dentists have a poor understanding of coding and insurance laws. Add in teledentistry, and you have a recipe for an increase in insurance fraud and malpractice cases. Here's how you can stay in the clear.

Most dentists don’t understand their own insurance contracts, or the specifics of state laws. Add in the misinformation surrounding teledentistry, and you have a recipe for fraud—even if it’s not intentional.

The COVID-19 pandemic has impacted dentistry to a greater extent than any other issue in recent memory. It is unknown when or whether the disease will become endemic, similar to seasonal influenza.1 In response to the government-enforced lockdowns and social distancing guidelines, there has been a significant growth in the area of teledentistry, which is most likely here to stay.2

In my capacity as a dental insurance consultant and expert, I have concluded that the use of the new codes for teledentistry could increase the possibility of fraud.3 There is no doubt that all third-party payers will be auditing dentists billing for teledentistry. The dental profession will also see an increase in related malpractice cases.

With the advent of new teledentistry codes, a dentist’s chances of getting paid for a “procedure” will entirely depend on the insurance contract they signed or the Medicaid rules in a given state. There are also a large variety of state laws that govern what a dentist can and cannot do while treating a patient with teledentistry.

Related reading:
Teledentistry: One dentist's user guide

These legal and potentially fraudulent issues will be similar to those seen consistently by dentists who run afoul of “in-person” insurance laws and regulations. This will most likely be magnified with teledentistry. These are a few more the most significant problems:

  • Dentists don’t read the insurance contracts they sign.
  • Dentists do not know the specifics of their individual state dental practice act.
  • Dentists have little knowledge of what is written in their provider manuals.

Unfortunately, because of this lack of knowledge and understanding, dentists will be mandated to pay back large amounts of money to insurance companies and Medicaid. Dentists will also be liable for loss of licenses and, in some cases, jail sentences. Below, I present two examples of variations in state laws.

Alabama:4

  • Does Alabama allow for direct access to dental hygiene services? No. Note: In Alabama, dental hygienists are not required to go to an accredited school, but are required to have a license.
  • Can dental assistants help with teledentistry services? No, dental assistants may only function under direct supervision.
  • Does Alabama define “teledentistry”? Alabama Medicaid does not provide an explicit definition of “telemedicine.” However, the provider manual requires services to be provided via an interactive audio/visual system which allows two-way communication.
  • Is it possible to be reimbursed for teledentistry services? Reimbursement is allowed for live-video telemedicine only. No reference found for asynchronous services or for private payer laws.
  • Does Alabama provide a parity law regarding teledentistry? Alabama does not have parity laws in place and has no pending telemedicine legislation.

Alaska:4

  • Does Alaska allow for direct access to dental hygiene services? Hygienists who have obtained a collaborative agreement may provide their entire scope of practice in settings “outside of the usual place of practice.” Hygienists practicing under general supervision can practice without the onsite presence of a dentist as long as the procedures are authorized and being carried out in accordance with the dentist’s diagnosis and treatment plan.
  • Dental health aid therapists (DHAT) are permitted to provide services under general supervision. DHATs are not dual-licensed as dental hygienists, although they can provide some of the same services.
  • Does Alaska allow dental assistants to participate in teledentistry services? Dental assistants must work under the indirect/direct supervision of a dentist.
  • How does Alaska define teledentistry? While the state does define telemedicine/telehealth, it does not specifically define teledentistry.
  • Is it possible to be reimbursed for teledentistry services? Medicare will reimburse for synchronous and asynchronous services.
  • Does Alaska provide a parity law regarding teledentistry? Alaska does have parity laws in place that allow coverage of telemedicine under private insurance and Medicaid.

Record-keeping: More is better

One bright note is an American Academy of Pediatric Dentistry publication entitled “Record-Keeping.”5 The academy has done a great job instructing dentists on proper record-keeping, which can be a template for any phase of dentistry. I have reproduced below the paragraph concerning teledentistry:

“Dentists are encouraged to understand their state’s regulations regarding documentation and consent requirements for teledentistry. Documentation of a teledentistry patient visit should include a thorough description of the encounter in accordance with state regulations as part of the patient record. Security measures and privacy of protected patient information should be maintained in compliance with state and federal laws.”5

I further recommend the ADA publication “D9995 and D9996 – ADA Guide to Understanding and Documenting Teledentistry Events” to comply with local rules and laws.6 This is an excellent publication that will be very helpful to all who read it. These are the components of a dental code as defined by the ADA. Remember, you must bill for what you do and do what you bill.

  • Code: A five-character alphanumeric code beginning with the letter D
  • Nomenclature: A written, literal definition of a dental procedure code
  • Descriptor: A written narrative that provides further definition and the intended use of a dental procedure code

The biggest problem I have seen is that the records do not reflect the literal definition of the code. Incomplete records or the use of general templates have caused almost all the fraud and malpractice cases lost by dentists.

Here are my suggestions for must-haves in your records:

  • The time and type of contact (e.g., phone call) and the time it finished
  • If possible, record the interaction
  • Name of any other person on the call
  • Why the patient called
  • If the call is after hours, make sure you record everything in the patient record as soon as you get to the office and note why you could not record the call at the time it happened.
  • Assuming your staff will bill the insurance, Medicaid, or patient, the dentist should review the record.

I know this can be onerous. However, good record-keeping is your ultimate protection. Every lawyer I have worked with has said to me, “more is better” concerning keeping records.

Editor's note: This article appeared in the December 2021 edition of Dental Economics.

References

  1. Pormohammad A, Ghorbani S, Khatami A, et al. Comparison of influenza type A and B with COVID-19: A global systematic review and meta-analysis on clinical, laboratory and radiographic findings. Rev Med Virol. 2021;31(3):e2179. doi: 10.1002/rmv.2179
  2. Ben-Omran MO, Livinski AA, Kopycka-Kedzierawski DT, et al. The use of teledentistry in facilitating oral health for older adults: A scoping review. J Am Dent Assoc. 2021:S0002-8177(21)00360-3. doi:10.1016/j.adaj.2021.06.005
  3. Gill JK, Aghili S. Health insurance fraud detection. Concordia University of Edmonton. December 2020. https://era.library.ualberta.ca/items/e68678e1-1021-4e4c-8fa2-54455deb9fd0/view/b4448595-ee64-413c-8e46-ce8e349a57da/Gill_2020_Fall_MISAM.pdf
  4. Teledentistry quick facts: State-by-state guide. Mouthwatch. https://www.mouthwatch.com/wp-content/uploads/2020/08/Mouthwatch-50-States_8-2020.pdf
  5. Record-Keeping. American Academy of Pediatric Dentistry. 2021. https://www.aapd.org/globalassets/media/policies_guidelines/bp_recordkeeping.pdf
  6. D9995 and D9996 – ADA Guide to Understanding and Documenting Teledentistry Events. American Dental Association. March 2020. https://www.ada.org/~/media/ADA/Publications/Files/CDT_D9995D9996-GuideTo_v1_2017Jul17.pdf