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Professional News Articles : : ON PRACTICE MANAGEMENT by Janyce Hamilton : Avoiding the missteps toward insurance fraud

Avoiding the missteps toward insurance fraud

February 03, 2006

Every year, Stephen W. Connaghan, an accredited healthcare fraud investigator, is busy checking dentists' records and busting them. As manager of United Concordia's Special Investigations Unit (SIU), in Harrisburg, PA, it's his job. Most insurers have the equivalent of a Stephen Connaghan because they are losing money through fraudulent claim submissions.

Healthcare fraud experts or program safeguard entities, such as the National Health Care Anti-Fraud Association, estimate overall healthcare fraud impacts 3% to 5% of the total monies spent on overall healthcare services—approximately $60 million. Dental services make up approximately 4.9% of the overall healthcare dollars, which is approximately $98 million annually. Thus, between $2.9 million and $4.9 million are impacted by fraud each year. Mr. Connaghan is good at what he does. The U.S. Health and Human Services Office of the Inspector General gave him the 1995 Inspector General's Integrity Award.  He's received other accolades as well.

This month, I had a conversation with him so the entire staff of your dental practice can learn what he has observed in during the last decade on the job. This may help motivate some to keep the records and billing practices above board, if they are not already.

The Interview

Janyce Hamilton (JH): What might a typical work day involve?

Stephen Connaghan (SC):  As manager of SIU, I monitor incoming fraud complaints, case resolutions, pending federal/state law enforcement agencies referrals and daily activities of SIU staff (one senior investigator, two  investigators, and one end-of-line quality control analyst).

JH:  I don't read much about dental fraud in the mainstream dental publications, where can I go?

SC: There are publications, for example, BNA's Health Care Fraud Report, which reports private sector, federal and state news; court proceedings; healthcare program exclusions; etc. One website that I find extremely useful is: http://www.topix.net/business/dental.  This website strictly deals with dentistry news on a national, as well as, international scope.

JH:  How does a dental insured customer find out that someone is using their identity to commit dental fraud?

SC: As an example, I'll tell you about a case. The SIU received a fraud complaint letter from an insured, who claimed someone else was utilizing United Concordia dental benefits. She was estranged and divorce from her husband for approximately two years. She was insured through her employer by another dental insurance company. Her ex-mother-in-law, who lived with her son, saw a United Concordia dental explanation of benefits (DEOB), and since it was address to her ex-daughter-in-law, she provided it to her.

Once the complainant opened the DEOB, she saw that numerous dental services were paid for under her name by United Concordia.  She provided the SIU a personal photograph (driver's license photo) and current dentist patient records which showed she was enrolled in a Phase II - Adult Orthodontia program. During the course of SIU investigations, working with the ex-husband's employers and the local district attorney's office, it was determined the sponsor (spouse) never removed his ex-wife's name from the employer's dental benefit plan. The sponsor allowed his “significant other” to utilize the dental benefits provided by his employer. Both the sponsor (the employee enrolled in the group benefits program through his/her employer) and girlfriend pleaded guilty to identify theft, conspiracy to commit fraud and insurance fraud. Each received three years of supervised probation and had to pay $1,100-$1,300 in criminal restitution.

JH:   It is apparently too tempting for some to commit insurance fraud, but doesn't the perpetrator economically hurt him or herself in the end, even if not caught?

SC: Any type of fraudulent activity negatively impacts the cost of providing dental benefits and ultimately affects premium rates, which affects dentists and patients alike.

JH:   Can you outline examples of how dentists or their business office/billing staff have manipulated billing and treatment records to get payments?

SC:  

• Type/number of services provided: (This is when the dental practice) adds additional service for increased reimbursement. Most attempts are for non-rendered services.
• Date of service: (This occurs) when the expiration of the annual dental benefits period is close and a member has either reached annual maximum benefit for the year or there is a time limitation regarding a dental service. The dentist or his/her
  staff recommends to the patient the following: “Our office will correct
  today's dental problem, however, the dentist or staff shall not bill until
  the new benefit period” and submits a fictitious date of service, because
  he/she will have new dental benefit coverage period.
• Services reported: (This is) billing for non-rendered services and/or up-coding the procedure--billing a service at higher reimbursement level. (An example would involve the dental practice billing for) four quadrants of scaling and root planing when, in fact, the service rendered was a prophylaxis.
• Patient's cost share/co-payment collection: Some dental practices have waived the patient's cost share of the co-payment by simply not collecting it. In this case, the dentist may be inflating services performed (up-coding). In the above example, “four quads of scaling and root planing” may be written down on one day, when in fact only a prohylaxis was performed.

Most states and federal/state healthcare funded programs (TRICARE, Medicare, Medicaid, etc.)  do not permit routine waivers of patients/members to share costs or make co-payments.  A patient, subscriber or member will mostly likely not report alleged fraud or schemes if he/she is not being billed by the dentist. The SIU questions this activity to determine if additional fraud may be identified. Waiving cost sharing or co-payments generally involves the dentist inflating his/her fee to the insurance company.

JH: Why do people knowingly commit fraud, typically?

SC:  It is not traceable to just one specific reason. There are a variety of reasons why individuals may commit fraud, including: greed, self-esteem,community status (perceived wealth) and/or a substance abuse problem.

JH: Is your job just to investigate your company's potential losses or do you follow-up on Medicare mischief too?

SC:  If our SIU identifies a dentist or entity allegedly committing dental insurance fraud and we suspect the individual or entity is committing fraud against other insurance companies, we will contact that company's SIU to discuss our investigative findings. Medicare coverage for dental services is very limited in scope or not available at all.  However, we may contact the state Medicaid Fraud Control Unit (MFCU) to discuss investigative findings, as well as determine if the MFCU has a past or pending criminal investigation.

Most dentists or entities who commit fraud are non-discriminatory.  If he/she is committing insurance fraud against one insurer, he/she normally is submitting false claims to all insurers.

JH:  What's the shortest and longest sentencing and range of fines you've witnessed?

SC:  Probation to eight years of imprisonment, and for criminal/civil restitution: $1,000 to $1.2 million.

JH: Can you provide a “cheat sheet” of what every dental office should post as a checklist of sorts so that they don't accidentally get into trouble with fraud?

SC:  There is no cheat sheet. Any person who knowingly and with intent to defraud an insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties. Submit truthful claims for services which were rendered and maintain adequate patient records that documented the diagnoses and treatments performed.

JH:  If someone finds something that doesn't fit, what should they do?

SC:  Dentists, hygienists, subscribers, beneficiaries, corporate partners, federal or state agencies or anonymous sources can report suspected fraud or allegations on-line by visiting http://www.ucci.com/fraud.html  (Commercial Lines-of-Business) or http://www.tricaredentalprogram.com (TRICARE Dental Program).  The complainant is provided the following two options:

• Print United Concordia's “Fraud Complaint Form” and mail it to the SIU;
• Complete “Fraud Complaint Form” online and e-mail the form directly to the SIU.

Anyone can contact United Concordia's toll-free “Fraud Hotline” at (877)968-7455 to report suspected fraud or allegations as well.  The telephone number is operational 24/7. The caller is prompted to leave a detailed voice message concerning the suspected fraud he or she has encountered.

The SIU monitors the online fraud e-mail mailbox and hotline daily to ensure complaints are handled expeditiously.

JH: In your opinion, what percentage of dental fraud is eventually detected?

SC:  4% of dental fraud is probably detected.

JH: Fudging details to get payment for a few hundred dollars from an insurance company may seem harmless” to some, who see insurance conglomerates as big, faceless, moneymaking entities like banks.

SC:  But many employer groups are experiencing double digit premium increases regarding their healthcare expenditures and retirement healthcare benefits programs.  Insurance fraud impacts the healthcare premiums which are offered by insurance companies. Companies are searching for avenues to stabilize these costs, for example, closure of plants, layoffs, benefit reduction (terminate dental coverage) and/or employee contributions.  United Concordia's Senior Management team views our SIU as an essential piece of the puzzle. We are entrusted with maintaining the fiduciary commitments made by our corporate companies, as well as, the dental community to ensure dentists who commit fraud are prosecuted or removed from our networks. I suspect many dentists within a given geographic area or community know the dentists who cheat the system or provide an unacceptable standard of dental care to his/her patients. However, they are reluctant and afraid to come forward.  Our SIU provides the avenue to report suspected dental fraud anonymously.

JH:  I noticed at the medical doctor's office, they are starting to ask to photocopy driver's license for a picture of the insured to be on file, will this come to dentistry?

SC:  It would be beneficial for all healthcare providers--hospitals, medical providers, dentists or dental entities--to request photo identification, just not the insurance card of the member.  Dentists or entities that have experienced identify theft issues, usually introduce this practice following an event.

Conclusion

Continue to be careful with insurance billing. Resist the temptation, for example, to “work with the patient's insurance” in billing for services using a different date so that they can maximum their benefits. It might make you popular with your patients, but in the eyes of the insurance company, it turns out that this little convenience is called fraud.

Janyce Hamilton is a Chicagoland freelance dental writer and editor. If you have a suggestion for topics to be covered, or any comments on this column, drop us a line, review@cds.org.

Copyright 2006, Chicago Dental Society