Can You Lose Your License Because of Billing Practices?

Massachusetts law is quite clear and specific about the Board of Registration in Dentistry’s powers to suspend or revoke the Massachusetts license of the dentist found to have engaged in repeated billing irregularities. Massachusetts General Laws Chapter 112 Section 52E gives them that power if, after due notice and hearing, a dentist is found to have billed an insurance company for money in excess of the amount usually received for the services provided, falsely reporting either treatment dates, charges or services rendered, or violating co-payment provisions of an insurance contract.   The Massachusetts Dental Regulations repeats the wording of the statute in its requirements for license applications.

There is an important question of what level of errors in practices amounts to “repeated irregularities” and whose errors the dentist is responsible for if the Board investigates charges and tries to suspend or revoke a license? A dentist might have benefited from the billing errors, but when is his or her knowledge of the practices enough to constitute fraudulent billing or irregularities? There have been a number of cases where the employees of the dentist are actually the ones benefiting from the practices, and then pocketing the excess monies when obtained.   Then not only is there a case for fraudulently billing an insurance company or patient, but a fraud committed against the dentist.

If the alleged conduct is clearly not intentional the standard for alleging fraudulent billing practices is not met, and only rises to that level if a dentist knew or should have known that submission of false claims by employees took place. Actual knowledge, reckless ignorance or other special circumstances have allowed courts to uphold suspensions. Affixing the rubber stamp of a dentist on a claim form for unnecessary services or services not performed may not be considered enough to warrant discipline, particularly if no direct benefit to the dentist occurs.

An interesting difference in the standard between fraudulent billing and “repeated irregularities” has taken place in Missouri, where the legislature actually changed the statute after a court disallowed the suspension of a dentist because there was no intent to submit false claims. After the amendment to the statute intentional misrepresentations were not required for disciplinary action to take place, but just irregularities.

The courts often defer to the Board when there are difficulties actually determining whether the actual services were performed which were charged to insurance plans. When an Alabama dentist had his license suspended because he increased the number of tooth surfaces involved in restorations which he billed for payments, the court upheld the suspension without expert testimony because of the experienced dentists making up the Board.

Performing unnecessary services is not explicitly mentioned in the statute as a prohibited action meriting disciplinary action, but courts have awarded damages for repeated unnecessary work done. An investigation in Texas is now ongoing for unnecessary orthodontic work done on minors by particular dental practices seeking Medicaid payments.

So how does a dentist avoid the possibility of an investigation into billing irregularities which could result a reprimand, suspension or revocation of a license by the Board? Having a third party take care of billing insurance companies for services is a way to avoid the accusation of intent or direct participation in excess billing. Terrance Patterson of Practice Management Solutions in Attleboro, MA recommends that a regular audit of billing practices take place to ensure that proper billing practices are being used and the right coding is used to bill for dental services. Employees of a dental practice inexperienced in proper coding of insurance claims can commit multiple irregularities which, if not recognized and corrected by the dentist, can constitute the requisite “knew or should have known” standard for a justified Board investigation.

The current trend in the regulation of health care providers ordering excess treatment which may be more costly is now an issue in the Massachusetts legislature, and it is likely the Board of Registration in Dentistry is going to be under pressure to investigate overbilling practices more thoroughly.



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