Behave ... or be punished!

April 1, 2003
This is in response to the "Dental Reimbursement" column by Tom Limoli Jr. in the December 2002 issue of Dental Economics.

This is in response to the "Dental Reimbursement" column by Tom Limoli Jr. in the December 2002 issue of Dental Economics.

I read another one of these columns that pretends to assist us in efficiently navigating the dental insurance portion of our practice duties. I must remember to never read these articles before retiring at night, because they consistently have the effect of delaying my trip to dreamland.

As with most of these dental reimbursement columns, Dr. (oops!), Mr. Limoli's column implies that any difficulties encountered by the dentist are of the dentist's own making (or that of his staff). He tells us that diagnosis cannot be delegated to those corporate entities and benefit plans — that they are nothing more than money managers and administrators. He ducks the issue of the intense pressure these companies put on the shoulders of that professional making that diagnosis. He ducks it to the point of trying to convince readers that such pressure is a fictitious scapegoat of whiny dentists who don't have the self-discipline to follow the rules.

These articles tell us that if all of our i's are dotted and the t's are crossed, these corporate entities will gladly reimburse us for the services they cover. They tell us that the roadblocks we encounter in dealing with these entities are all of our own making. Sure! I suppose that's why Company A sends me a letter saying that my claim and my X-rays are being sent for further review, then tells me several weeks later that they never got my X-rays. I suppose it is our problem when there is an error on the insurance form and they won't allow us to correct the error over the phone or by fax.

I remember listening to a tape of a lecture of a dental consultant for an insurance company. This consultant related a story about a dentist who complained to the State Commissioner on Insurance about how his claims were being handled. The consultant said, "That doctor can complain all he wants, but now he's on my restricted payee list! That means that all of his claims have to cross my desk first." Well, another night's sleep shot!

Did anyone see the "60 Minutes" report about an eye surgeon who came down with Parkinson's disease? After several months, the disability insurance company terminated his benefits without cause. Some women who worked (or used to work) for this disability carrier testified that their money managers told them that they must find a reason to close a certain dollar figure's worth of claims each month!

This is the industry we find ourselves in contention with, while trying to provide quality care to our patients. Please don't talk to us as if this is not the case. A little expression of empathy towards the dentist might make us more receptive to the rest of the information you have to offer. Until then, articles like "Don't Treat Based on Benefits" by Dr. (oops again!) Mr Limoli are of little assistance to the present practitioners of his father's sacred profession.

Michael Steinberg, DDS
Brooklyn, NY
[email protected]

Response from Tom Limoli Jr.

I must have really struck the trigeminal nerve of Dr. Michael Steinberg. Not only did I get his attention, but I seem to have reached his conscience. I'm so sorry to be keeping the good doctor from his nocturnal journey to dreamland, but I make no such apology for having shaken the very core of political dogma. I am, with great honor, preparing my father's "sacred profession" for the challenges of tomorrow, rather than empathizing about the arcane principles of yesterday.

When did it become the responsibility of our federal government to determine appropriateness of care? I'll tell you! It became their responsibility the minute you placed a stamp on the envelope and/or electronically transmitted the claim. If you think HIPAA is all about patient privacy and arbitrarily redefined procedure codes, you might want to ask an attorney about the Title 18 sections of the U.S. Criminal Code that have already been added to HIPAA.

Since my nondentist perspective so greatly offends Dr. Steinberg, direct him to the 2002 William J. Gies award-winning editorial titled "Insurance Fraud" by Milton Houpt, DDS. He can find it at www.ada.org or read it here.

Tom Limoli Jr.
Atlanta, Ga.
www.LIMOLI.com

Insurance fraud

by Milton Houpt, DDS, PhD
Editor, Pediatric Dentistry

Upon returning home from an out-of-town trip, my wife found a telephone message from the fraud division of her credit card company. Apparently, when she used her credit card at a restaurant, someone had copied it and used the copy to make large purchases in various parts of the county. Understandably, anyone would feel outraged and hope that the perpetrator would be caught and jailed for this blatantly fraudulent behavior. Yet, do we respond similarly to instances of a different type of fraud, one perpetrated by health-care professionals upon insurance companies?

It was at a state dental meeting, during which attendees were discussing various practice-management issues, that I was dismayed to hear the comment, "We never place fissure sealants in our office, only composite restorations." The practitioner explained that restorations were placed because that was what insurance companies covered, whereas some did not provide coverage for fissure sealants. I wondered how frequently practitioners misrepresented their treatment and whether that misinterpretation constituted fraudulent behavior that differed from the use of my wife's stolen credit card.

This question led me to call the fraud division of a large dental insurance company. I learned that for insurance companies, fraud is a major concern, not simply an isolated event. Insurance fraud is not limited to a particular type of practitioner. It occurs just as frequently in practices that are large and small, urban and suburban, solo and group, and new, as well as long-standing. It seems that no type of practitioner is immune to fraudulent behavior and, consequently, this is a concern which needs to be addressed.

According to an insurance industry spokesperson, fraud is defined as "a practice in which a person knowingly and intentionally altered information provided to the insurance company." Many examples were provided, such as changing dates on insurance forms so that a service would fall at a time within the patient's coverage period to guarantee reimbursement; the undisclosed waiver of patient copayment and acceptance for private payment of only the amount reimbursed by the insurance company; and the existence of two fee schedules, one for paying patients and one for patients covered by a third party. Most troubling is the submission of a bill for one procedure when, in fact, another was actually performed, such as stating that a surgical extraction, rather than a simple extraction, was performed, or stating that a composite restoration was placed, rather than a filled-fissure sealant. Two different motives could explain why practitioners fudge the information — either benefit for the patient or financial gain for the practitioner. In either case, the behavior is wrong, though one might be more sympathetic to the motivations of the former as opposed to the latter.

Though it is clearly improper, fraudulent behavior by health-care providers is a complex issue. In a study appearing in the April 2000 Journal of the American Medical Association, titled "Physician Manipulation of Reimbursement Rules for Patients, Between a Rock and a Hard Place," researchers reported the extent to which physicians manipulate rules of reimbursement by insurance companies to obtain coverage to benefit patients. Some 720 practicing physicians responded to a survey asking how frequently they exaggerated the severity of a patient's condition, or changed the billing diagnosis, or reported nonexistent signs or symptoms, in order that patients might benefit. Discussion with other medical colleagues indicated that this kind of behavior is widespread and longstanding. Yet, while this behavior might be rationalized, it is nevertheless still considered by the society to be fraudulent and, consequently, inappropriate.

The January 10, 2001 New York Times reported under a bold headline, "Doctor Convicted of Insurance Fraud in Fertility Procedures," that "a Manhattan obstetrician with a celebrity clientele was convicted of defrauding insurance companies to have them pay for expensive fertility procedures. The doctor was convicted of something that many in his profession have quietly done for years: Billing insurance companies for covered gynecological procedures to mask the uncovered fertility procedures that he was performing." While that physician might have claimed that his behavior benefited his patients, nevertheless, he was found guilty of fraud and unless he wins an appeal, he will be spending many years in jail.

*Reprinted with permission from the American Academy of Pediatric Dentistry, 211 E. Chicago Avenue, Suite 700, Chicago, IL 60611-2663, phone (312) 337-2169, fax (312) 337-6329, email [email protected], Web site: www.aapd.org.

Hungry, Hungry HIPAAs

Someone passed along Joseph Epstein's January Dental Economics article on HIPAA. I was actually amazed at the tone of the article, and I followed the link to his Web site information about HIPAA. I was very surprised to see that what you said about HIPAA and privacy was pretty much totally inaccurate:

"The privacy section of HIPAA concerns transmittal of electronic data. Even normally reputable sources have piggy-backed their notion of privacy laws as a part of HIPAA, but it is your state's privacy laws that govern the manner in which you handle privacy issues in your office. HIPAA does not mandate offices to change their charts, hide patient names, or put blinders on their computer screen."

Without going into much detail, HIPAA sets a floor for privacy and security issues. If your organization is covered by the HIPAA rule by virtue of you using electronic reimbursement, HIPAA absolutely does require certain physical and administrative actions and safeguards about patient information. Your state law applies only if it is more stringent than HIPAA.

Your stance on HIPAA is not shared by anyone else I know in state or federal policy (including the AMA and the ADA), and I would be interested to know how it came about.

Lewis Lorton, DDS, MSD
HIPAAdocs Corp
Columbia, Md.
www.hipaadocs.com

Reply from Mr. Epstein

Your amazement at the tone of my article is indicative of the extent to which the privacy aspects of HIPAA have overshadowed other aspects of the law. The quote you selected was not from my article, but from the Web site, www.n2odental.com. I believe that the quote was accurate at the time of writing, since no final rule on privacy had been published. The privacy rule was only submitted for publication on February 13 — well after the article was published and your response. The tone of my article and of the information on www.n2odental.com might be called anti-inflammatory because they attempt to calm nervous dentists and demonstrate that there is, in fact, a good reason for all of this change!

Consider the very first words of HIPAA:
"SEC. 261. PURPOSE.

"It is the purpose of this subtitle to improve the Medicare program ..., the Medicaid program ..., and the efficiency and effectiveness of the health-care system, by encouraging the development of a health-information system through the establishment of standards and requirements for the electronic transmission of certain health information."

I believe that talk of HIPAA privacy should be considered with respect to the legislation's larger goals of increasing efficiency, reducing costs, and providing higher quality care. The best way to achieve these goals is through cutting-edge software.

Joseph Epstein
Glitz Dental
Brooklyn, N.Y.
www.glitzdental.com

Help with office design

I read your Editor's Notes column in the February issue of Dental Economics. I am writing to express my gratitude to a colleague who went out of his way to help me with plans for my new office.

I originally read about Dr. Ellis Disick in your column about the efficient use of a limited amount of office space. I required a similar rectangular design for my new office building. Dr. Disick sent me his blueprints and numerous suggestions. I thought it was great that a colleague in New York would help me out in Indiana.

Thank you for your kindness Dr. Ellis Disick of White Plains, New York!

John W. Susott, DDSC
Westfield, Ind.

OSAP Symposium June 19-22

Dentistry's premier infection control and safety resource, the Organization for Safety and Asepsis Procedures (OSAP) is pleased to announce plans for its upcoming annual symposium for clinicians, staff, researchers, educators, policymakers, and industry representatives.

With its focus on the revised Centers for Disease Control and Prevention's (CDC) dental infection control guidelines, the continuing-education accredited OSAP 2003 Symposium will be held June 19-22 at the Westin La Paloma Resort in Tucson, Ariz.

The 2003 OSAP program is currently being finalized. OSAP members can expect to receive a program and registration information in the mail shortly. For more information, call the OSAP central office at (800) 298-OSAP, or (410) 571-0003.

The Westin La Paloma is already accepting reservations for the rooms at the OSAP rate of $110 per night. Call (800) WESTIN-1, or direct at (520) 742-6000 to book.

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