Posted and filed under Dental, Fraud, FWA.

This week’s Fraud Spotlight features guest contributor Mark R. Brengelman, JD, MA. Be sure to tune into the column for more expert insights from our network of providers, investigators, and fraud experts.

…What do the records say?

This article points out additional violations of law related to fraudulent dental misconduct – medical records forgery or simple lack of documentation. A dentist risks disciplinary sanctions for lack of appropriate documentation even if forged documentation cannot be established.

Billing for the extraction of two teeth when only one tooth was extracted is a prior example. Such an investigation involves the comparison of the procedure’s billings and the dental records of the patient to be proven by the dentist’s documentation – an isolated event or a pattern.

The dentist may explain the billing for two extractions was justified, but it was clerical oversight not to document both teeth were pulled. Or the dentist may give a mea culpa and say the billing for two extractions was in error because the dental records were correct showing only one extraction. 

Again, isolated event or pattern?

Even so, based on the financial billings and dental records, at least one violation may be proven when fraud is suspected: “failing to keep written dental records and medical history records that justify the course of treatment of the patient.” Under such a disciplinary standard, the dentist could be sanctioned with a reprimand, administrative fine, and required continuing education – on dental record-keeping, of course. This discipline would be for the mismatch between the clinical records and the financial billings, but not from a finding of fraud.

Further proof requires a clinical examination of the dental patient to see just how many teeth they still have! When a dentist performs one extraction, bills for two extractions, then marks the dental record as two extractions being performed, a records review would not prove the fraud because the dental records and the billings match.  

As an investigator for a dental board, Medicaid, or an insurance company, did you think you must examine the patient directly? 

Hire a dentist to perform an independent dental examination then compare that to the billings and clinical records in question to see if there were fraudulent billing and record-keeping violations for forgery or lack of documentation.

Dental practitioners need to know how their billings are compared to their medical records to the actual clinical status of the patient. Inconsistencies result in disciplinary action against the dentist’s license for “obtaining a fee by fraud or misrepresentation” as well as “failing to keep written dental records and medical history records that justify the course of treatment of the patient” even if evidence of forgery is lacking.

About the Author

Mark R. Brengelman, JD, MA, practices health care law in Frankfort, Kentucky, where he is the immediate past Chair of the Health Law Section of the Kentucky Bar Association. For fifteen years, he was the Assistant Attorney General assigned as General Counsel and Prosecuting Attorney to the Kentucky Board of Dentistry. His e-mail is Mark@MarkRBrengelmanPLLC.attorney.