Roy S. Shelburne, DDS
It’s been more than a decade since I was released from prison for doing something I did not do—I did not put into place the systems and processes that would ensure that my practice was compliant with billing and coding. Since my release from prison and return to dentistry, I’ve spent time as a speaker, writer, consultant, and coach sharing my experience with my colleagues so that they can do what I did not do to minimize their risk of exposure. As I like to say, I did the time so you don’t have to.
Delivering an exceptional patient experience should be your team’s number-one priority. A close second should be keeping accurate and comprehensive records. This includes setting standards, training all team members on their roles and responsibilities so that they can consistently meet those standards, and strategic auditing of the systems and processes.
Here are three steps that will help you on the road to compliance. Of course, these steps are not comprehensive as every practice and team is unique, but they can be used as general guidelines to create your own standards, policies, and procedures.
Step 1: Implement compliance and practice standards
To start, you need to know what is required to be in the patient file, or what the standards are, each and every time there is patient communication or care. Because each state differs, as a starting point you can get your required standards from your state association. But remember, ultimately it is the doctor and team’s responsibility to ensure that the records contain all the information to support the necessity and legitimacy of billed treatment.
Because compliance includes everything to do with patient communication and care, start by making a list of the systems, processes, and documents. Begin with the patient’s health history. Standards should detail what is included, how it is documented, when and how it is updated, who updates it, when it is to be reviewed by the doctor, and how to document that the doctor reviewed it.
Now, let’s look at the all-important patient record. This record should contain:
• the treatment plan;
• the updated health history with informed consent documented;
• informed refusal;
• detailed assessment of the patient;
• telephone conversations with the patient;
• treatment rendered;
• subjective complaints;
• detailed subjective and objective findings that support the treatment plan;
• reasons for deviation from original treatment plan;
• patient noncompliance or failed appointment(s);
• routine full-mouth periodontal probing;
• highly detailed records for complex cases;
• post operative instructions;
• referral to or consultation with another practitioner;
• comments about the cost of treatment and the patient’s payment history;
• x-rays that demonstrate the necessity of the treatment plan;
• prescription orders; and
• the name and relationship of the person who gave consent for minors or for patients who are incapacitated.
As you can see, creating standards and the systems and processes to ensure compliance need to be thorough and detailed.
Step 2: Designate a compliance officer or contact
Although the doctor is ultimately responsible for compliance, it’s important to have a team leader who will advocate for the standards and documentation. This should be the person most responsible for the practice processes, such as the office manager or administrator. Here are a few of the person’s key responsibilities.
Develop and lead team training to ensure everyone knows the standards required to be compliant, and everyone has the proper training so that they can be held accountable for their roles in the process. It’s important that the team have open lines of communication and help each other understand the importance of accurate documentation on every patient, every time. There must always be time in the schedule to “do it right.”
Conduct internal monitoring and auditing to identify any noncompliant team members or adjustments that need to be made in the practice processes.
Respond to offenses and document correct action when there is inaccurate billing or coding. This demonstrates the intent to be compliant should an issue ever arise.
Enforce disciplinary standards through well-publicized guidelines for team members who are well trained, well informed, and have acknowledged their understanding of their roles and responsibilities yet are unwilling or unable to meet those requirements. You cannot put the practice, team, and yourself at risk because of one person’s performance.
Step 3: Evaluate your billing practices
Did you know that when you bill patients and allow them to make monthly payments on services provided, your practice may be considered a lending institution and may need to meet fair lending regulations? This is one area of compliance that’s easy to solve—avoid billing patients. Instead, use a third-party finance company such as CareCredit. Not only will you avoid the risk of exposure, but you’ll also worry less about cash flow and collections.
Now, let’s look at in-house membership discount programs. Having a formalized in-house membership discount program with complimentary services and/or fee reductions can accomplish many objectives: attract new patients, reduce cost barriers, increase revenue per patient, and increase repeat visits. Along with these benefits comes regulatory compliance. Currently, 35 states have discount plan operator (DPO) laws, with 23 states requiring licensure or registration, usually regulated by the department of insurance. In states without DPO laws, the attorney general regulates through consumer protection laws.
States have varied rules so it’s wise to check your state’s compliance standards. Some states require ongoing licensing and/or registration with the state. Some exempt providers offer in-house membership discount programs directly to their patients, but the exemption may apply only to the licensure requirement and not to the rest of the statute. Some states interpret the exemption to apply to single provider offices and not to DSOs or small groups. In some, the exemption is only applicable if the provider is not charging a fee for the plan. DPO laws may require a trial period where the member can cancel within 30 days and receive a full refund, less a nominal processing fee.
Designing and implementing a compliant in-house membership discount program can be daunting. To relieve some of the stress, some state dental associations provide kits that help with the design and compliance process. As an alternative, you can engage a company that specializes in in-house membership discount programs.
Compliance is confidence
This article is just a starting point. When you understand the standards needed to be compliant in every aspect of your practice and have the systems and processes in place to consistently meet those standards, you can be confident should the FBI ever come knocking on your door.
ROY S. SHELBURNE, DDS, is a 1981 honor graduate from Virginia Commonwealth University’s School of Dentistry. Dr. Shelburne opened his first practice in his grandfather’s old hardware store. He has served as president of the Southwest Virginia Dental Society and has volunteered at Virginia’s various Missions of Mercy projects. Dr. Shelburne collaborates with CareCredit to develop educational materials for the dental industry.
Disclosure: This content is subject to change without notice and offered for informational use only. You are urged to consult with your individual business, financial, legal, tax, and/or other advisors with respect to any information presented. Synchrony and any of its affiliates, including CareCredit (collectively, “Synchrony”), makes no representations or warranties regarding this content and accepts no liability for any loss or harm arising from the use of the information provided. All statements and opinions in 3 Steps to Documented Compliance are the sole opinions of the author.