A few months ago, the Atlanta Journal-Constitution reported on the guilty plea of an Atlanta dentist for Medicaid fraud.  Just this week, the dentist was sentenced to serve a year and a half in federal prison.

The dentist was alleged to have netted around $1 million in fraudulently obtained reimbursement from the Medicaid program.  As part of her plea agreement, the dentist agreed to forfeit her ill-gotten gains, including real estate that she acquired using the funds.

Some of the illegal activities alleged included:

• Having employees back-date claims for patients whose Medicaid eligibility had expired at the time the service was provided.

• Filing claims for services she provided on days she was not in the country; let alone in her office.

The alleged activities appear to have been intentional and deliberate.  Even so, the situation is instructive on the type of risks to which a dental practice can be exposed.  Even if the dentist had not instructed employees to back-date billings it would be possible for an employee to do this on their own initiative.  The dentist under whose name the bill is submitted would still be responsible for the fraudulent billing.  Criminal intent might not be present in such a case, but repayment and potential civil penalties would certainly be assessed.  The government’s inquiry would likely focus on “what the dentist knew and when he or she knew it.”  The stakes riding on the outcome of that analysis would be potential jail time or at least enhanced penalties.

So what is my point?  I recently wrote an article in which I described just some of the reasons a dental practice needs to have an effective compliance program in place.  Dental Practice Compliance Article.  The program should operate to educate staff on appropriate (and inappropriate) billing practices.  The program should include audits in areas of identified risk.  If a problem is discovered through proactive audit, appropriate corrective action should be taken promptly.  This may mean repayment and/or self-disclosure in some cases.  In other cases it may mean adjustment to policies and processes, additional training, or employee discipline.  It all depends on the circumstances.

One thing is absolutely clear.  If there is a problem in your practice, you want to be the one who discovers it.  It is still not fun to deal with, but at least you are not under active scrutiny by criminal or civil enforcement agents, or even worse, a potential whistleblower.  The way to stay out in front of these issues is to have a compliance program that proactively looks for problems as a matter of routine.

For some reason, many dental practices do not prioritize compliance.  Some practices believe compliance is mainly a “Medicare thing.”  That belief is wrong.  Medicaid and other governmental health programs apply, even when Medicare is not a significant source of revenue.  Compliance also goes beyond reimbursement issues.  A normal dental practice is subject to a host of federal and state statutes and regulations such as licensing requirements, insurance rules, OSHA regulations, DEA regulations, HIPAA, and state patient confidentiality laws, just to name a few.  Each of these areas present potential areas of risk and require mitigation through the operation of a systematic compliance program.