Improper Billing for Federal Reimbursement

Dentists improperly billing for Medicare or Medicaid reimbursement is becoming big news these days, with the December 11, 2012 NBC’s Today Show’s feature of the Small Smiles Dental Texas case of Medicaid fraud in billing for unneeded services for orthodontic and dental care of children. That case highlighted both the negative impact on the children of having unneeded root canals, caps and other dental work at young ages, all of which was billed through Medicaid for reimbursement of Small Smiles as a dental provider. It is appropriate to review the federal regulations designed to prevent Medicare fraud and abuse, considering these and other cases and the hefty civil and criminal sanctions now being levied against the participants.

The federal government defines many of the billing techniques used to defraud Medicare for reimbursement as “upcoding.” The Department of Health and Human Services and the Office of the Inspector General list a number of specific examples of billing practices which would be considered Medicare fraud.   Billing for services not actually rendered is the one of the most glaring examples of this kind of violation, and is of course, the most easily recognizable if the patients’ names are provided but are actually fictitious or were not seen on the day claimed for the service. If the patient was present and was not provided the particular service, there is living proof that the service was not provided as stated in Medicare reimbursement forms or is not evident in treatment plans.

When a treatment is not medically necessary or unnecessary, then treatment in order to obtain reimbursement from Medicare or Medicaid is considered fraudulent.   Because dentistry is sometimes considered a cosmetically oriented medical treatment, Medicare does not cover dental work that is not directly related to a physicial health condition.   For instance, there have been particularly compelling cases in which treatment for cancer in the facial area results in need for significant dental work just to maintain a reasonable quality of life, both for eating or drinking and for appearance reasons. Medicare has consistently sided against reimbursing dentists for these procedures. When a dentist performs treatment which is too far removed from a physical condition to be considered directly related, if it is done specifically to obtain Medicare reimbursement then it would be considered fraudulent.

With regards to Medicaid reimbursements for unnecessary treatment, the Small Smiles case is one illustration of the rampant abuse of this type of Medicaid fraud. When dental insurance is available for coverage, and the dentist convinces the patient that it needs to be done, and performs the treatment even though it is not really necessary, the result is Medicaid fraud. Often the patient is the unwitting participant, particularly when he is presented with the plan quickly and agrees to the procedure that day. When children are involved, the effects of extensive unnecessary dental treatment at such a young age can be considered psychological as well as physical abuse.

Billing for procedures where there is improper supervision by unlicensed or untrained personnel is also a key example of where a Medicare or Medicaid claim will be turned down, and may be considered fraudulent if done knowingly. The recent addition of complex supervision requirements in the Massachusetts dental regulations for dental assistants, dentists, and hygienists for each procedure shows how easy this type of violation can occur.

Billing separately for services already included in a global fee can also come under the scrutiny of federal inspectors as a violation of federal law. Other coding based violations include billing for evaluation and management services for new patients, when the visit was actually a follow up visit. Coding is an area which should be particularly noted by dentists, since personnel not properly trained in submitting claims can make errors unknowingly which can lead later to accusations of federal insurance reimbursement abuse.