RAISING THE REIMBURSEMENT ROOF WHILE REDUCING REGULATORY RISK [email protected]www.royshelburne.com 276-346-3863 1
Transcript
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RAISING THE REIMBURSEMENT ROOF WHILE REDUCING REGULATORY RISK
[email protected] www.royshelburne.com 276-346-3863 1
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ROYS DISCLAIMER: I am not an attorney The comments and
observations made in this presentation are not to be taken as legal
advice The material shared is based on my understanding of best
practices The information I share is my opinion and is based on my
experience and subsequent research I cannot promise that
implementing the systems I recommend will ultimately prevent legal
action
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TODAY'S LEGAL ENVIRONMENT Malpractice Claims Insurance
companies have become much more concerned with identifying,
penalizing, and prosecuting healthcare fraud Board of Dentistry
Actions: Most citations are related to record keeping
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LEGAL DEFINITION OF INTENT Blind Disregard Who is ultimately
responsible?
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INSURANCE Conventional (Indemnity) PPOs HMOs Direct
Reimbursement Discount Plans
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I hereby certify that the procedures as indicated by date are
in progress (for procedure that require multiple visits) or have
been completed ADA C LAIMS F ORM L ANGUAGE
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T REATMENT P LAN $1,000 5% C ASH D ISCOUNT $ 950 What goes on
the form? $1,000 or $950? D ISCOUNTED F EE FOR P RE - PAYMENT
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D ISCLOSING C O -P AY F ORGIVENESS All states prohibit co-pay
forgiveness without third-party notification. Virtually all PPOs
prohibit co-pay forgiveness! If you forgive the co-pay in an
isolated situation, the remarks section should read: The patient is
not participating in the cost of treatment. Note: Always disclose
fee forgiveness to third-party.
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STATE AND ERISA PLANS Insurance (only applies to insured plans
under State Insurance Commissioner, not self-funded plans of large
employers ERISA) Employee Retirement Income Security Act of 1974
(ERISA)Retirement Income Security
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ERISA T YPE P LAN Employment Retirement Income Securities Act
(ERISA) a Federal Law. Controls accident and health plans and
retirement plans of self- employed and employers benefit plans.
Self-funded, not insured plans, are under ERISA. Self-funded plans
are often larger employers. Can fee cap for non-covered
procedures.
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P ROMPT P AYMENT L AWS Passed by all states Clean Claim is one
with all fields completed and complies with payers filing
(published) requirements. Clean Claims must be paid in 30/60 days,
according to state law. Prompt Payment Laws do not apply to
self-funded (ERISA) plans. Some PPO self-funded contracts spell out
the prompt payment policy, however.
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BILLING FOR OPTIONAL SERVICES Check with the carrier Discuss
with the patient Signed agreement from the patient Use the correct
corresponding code D_999 code Regular code Attach a copy of the
agreement with the claim
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OPTIONAL SERVICES Limitations on All Benefits - Optional
Services that are more expensive than the form of treatment
customarily provided under accepted dental practice standards are
called Optional Services. Optional Services also include the use of
specialized techniques instead of standard procedures. For example:
a crown where a filling would restore the tooth; a precision
denture/partial where a standard denture/partial could be used; an
inlay/onlay instead of an amalgam restoration; a composite
restoration instead of an amalgam restoration on posterior teeth.
If you receive Optional Services, Benefits will be based on the
lower cost of the customary service or standard practice instead of
the higher cost of the Optional Service. You will be responsible
for the difference between the higher cost of the Optional Service
and the lower cost of the customary service or standard
procedure.
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RECORD KEEPING LAW AND RECORDS RETENTION LAW The ADAs
Recommendations
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C AN YOU LEGALLY... Charge different fees for different people?
Charge different fees for different plans? Charge different fees
for same procedure code? Charge different fees for non-insurance
patient versus PPO Insurance patients?
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WHAT DELTA TELLS THE PATIENT: If the Dentist discounts, waives
or rebates any portion of the Enrollee Coinsurance to the Enrollee,
Delta Dental will be obligated to provide as Benefits only the
applicable percentages of the Dentists fees reduced by the amount
of such fees that is discounted, waived or rebated.
P ATIENT G IFTS FOR R EFERRAL Prohibited by many states law.
Prohibited by Medicaid or government- funded program.
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CREDENTIALING Name on the claim form as provider of
service
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FEES In-network charges Out of network charges
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PPO CONTRACTS Several pages only Refers to procession policy
manual Provide emergency care
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PPO CONTRACTS Agree to lower of PPO fee, or the practices
unrestricted fee Agree to same clinical protocol Agree to
non-discriminatory patient appointment times
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PPO CONTRACTS Agree to provide any and all information
requested Agree to audit on premises
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PPO CONTRACTS Audit paybackif audited, associate must pay back
money in 90 days. Agree to offset of payment in slow pay/disputes
Can terminate with 30/60 days Malpractice requirements and limits
Contract can be modified unilaterally by insurance company with
30/60 days notice Upgrades to basic PPO covered services
WHO GET AUDITED? Those who participate with PPOs You have not
choice. You must cooperate Those who do not participate with PPOs
You have a choice Bear the consequences
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AUDITS, WHAT TO EXPECT? In network or out of network? Audits
are performed to determine: That the procedure was performed That
the procedure was medically necessary That the procedure was not
cosmetic
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AUDITS Audits are performed to determine: That the fee charged
was the same fee charged to non-insurance patients in similar
circumstances That the clinical protocol for non-insurance patients
was the same clinical protocol for insurance patients in similar
circumstances That the procedure is not up-coded Example: A
surgical extraction (D7210) is charged instead of a routine
extraction (D7140).
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AUDITS That the claim form was accurate That the procedure was
properly represented by the current CDT - 2013 code reported Rights
if non-participating
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TOP CODES UNDER REVIEW 1. D4341, Periodontal scaling and root
planning, four or more teeth per quadrant
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TOP CODES UNDER REVIEW 2. D1110/D4910 on the same patient
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TOP CODES UNDER REVIEW 3. D2950, Core build-up, including any
pins
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TOP CODES UNDER REVIEW 4. D7210, Surgical removal of erupted
tooth requiring removal of bone and/or section of tooth
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TOP CODES UNDER REVIEW 5. D2391, Resin-based composite, one
surface posterior
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TOP CODES UNDER REVIEW 6. D2335, Resin-based composite, four or
more surfaces or involving incisal angle (anterior)
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TOP CODES UNDER REVIEW 6. X-raysof any kind
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TOP CODES UNDER REVIEW 7. Impactions
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SERVICES UNDER REPORTED: D0180: Comprehensive Periodontal
Evaluation New or Established Patient This procedure is indicated
for patients showing signs or symptoms of periodontal disease and
for patients with risk factors such as smoking or diabetes. It
includes evaluation of periodontal conditions, probing and
charting, evaluation and recording of the patients dental and
medical history and general health assessment. It may include the
evaluation and recording of dental caries, missing or unerupted
teeth, restorations, occusal relationships and oral cancer
evaluation.
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REATTACHMENT OF A TOOTH FRAGMENT, INCISAL EDGE OR CUSP
D2920
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RESIN INFILTRATION OF INCIPIENT SMOOTH SURFACE LESIONS D2990
Placement of an infiltrating resin restoration for strengthening,
stabilizing and/or limiting the progression of the lesion
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D4341/D4342 AND D4910 Perio Scaling and Root Planing
Periodontal Maintenance Do the math:
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PERIODONTAL MEDICAMENT CARRIER WITH PERIPHERAL SEAL LABORATORY
PROCESSED D5994: A custom fabricated, laboratory processed carrier
that covers the teethe an alveolar mucosa. Used as a vehicle to
deliver prescribed medicaments for sustained contact with the
gingiva, alveolar mucosa, and into the periodontal sulcus or
pocket: Perio Protect
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PALLIATIVE: D9110 Palliative (Emergency) Treatment of Dental
Pain Minor Procedure This is typically reported on a per visit
basis for emergency treatment of dental pain
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RECORD KEEPING ABOUT RECORD-KEEPING - BE DEFENSIVE. If it is
not in the clinical record 1. It was not seen 2. It was not said 3.
It was not heard 4. It didnt need to be done 5. It wasnt done 6. It
doesnt existfrom the legal perspective
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CLINICAL RECORD AND THE CLAIM They should mirror one another
The Clinical Record should record pertinent information and should
justify and support the treatment Evaluation X-rays What was
observed that helped in the treatment planning process Anything
surprising
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P RIMARY -S ECONDARY I NSURANCE Only determines the sequence of
insurance billing. Make no adjustment to patients account until
after secondary has paid. Primary-secondary status does not
determine the patients responsibility. The patients responsibility
is determined by the lower of the contracted fee schedules. Primary
payer for a child is determined by which parent whose birthday
comes first in the calendar year. The birthday rule can be
overridden by a court order (Divorce Agreement).
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COORDINATION OF BENEFITS Write-offs when to take them? COB
test
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THE MOST COMMON FRAUDULENT ACTS Billing for services,
procedures, and/or supplies that were never provided or performed.
The deliberate performance of medically unnecessary services for
the purpose of financial gain. Source: National Health Care
Anti-Fraud Association (www.nhcaa.org).www.nhcaa.org
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THE MOST COMMON FRAUDULENT ACTS Intentionally misrepresenting
any of the following, for purposes of obtaining a paymentor a
greater paymentto which one is not entitled: The nature of
services, procedures, and/or supplies provided or performed The
dates on which services and/or treatments were rendered ; Source:
National Health Care Anti-Fraud Association
(www.nhcaa.org).www.nhcaa.org
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THE MOST COMMON FRAUDULENT ACTS The medical record of service,
and/or treatment provided The condition treated or the diagnosis
made; The charges for services, procedures, and/or supplies
provided or performed; The identity of the provider or the
recipient of services, procedures, and/or supplies. Source:
National Health Care Anti-Fraud Association
(www.nhcaa.org).www.nhcaa.org
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MALPRACTICE CONSIDERATIONS Deviation from the standard of care
AND Injury Does stuff happen? Inform Handle the situation
appropriately
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FAILURE TO DIAGNOSE An evaluation indicates that a diagnosis
has been established or that arrangement to determine the diagnosis
has been made: Periodontal conditions Oral lesions
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PRESCRIPTION MONITORING PROGRAM:
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WHAT DO WE DO NOW? Honest Assessment Meet with the team
Determine where you are Decide where you want/need to be Develop a
plan Set your standards You get what you accept, not what you
expect Train Trust Review