Can your practice pass a risk management assessment?

Editor’s note: This is a compilation article written by team members of DIY Digital Dental Consulting about risk management, the process of identifying, assessing, and controlling threats to your capital and earnings. It’s your job to make sure those risks don’t become big problems. Here’s their hands-on advice.

Call in the experts

Risk management has many meanings in a dentist’s world and evokes several levels of emotion. It can mean your differential diagnosis of a patient’s condition and choice of treatment modalities, your human resource liability, your cybersecurity, your tax responsibilities, your legal situations, your insurance billing, and more.

These are only a few of the areas that dentists must be aware of. Throughout my career I’ve been motivated to continue my education to expand my knowledge and clinical expertise, as well as to manage my risks.

I reduced these risks in business by surrounding myself with the best professionals and then implementing their advice. I recommend that you hire experts in their fields. A dental-specific CPA will guide you about trends for maximizing current tax and government guidelines. A health-care human resources specialist is crucial, especially in these COVID times, when it comes to protocols and updated policies.

Dental hiring experts are aware of our needs, such as finding knowledgeable candidates, and hiring practices and pitfalls. During lease negotiations and practice transitions, a dental-specific attorney will protect you and your assets. Hiring these pros will reduce your risks and allow you to focus on what you do best—dentistry and patient care. —Jeanette Kern, DDS

Self-assessment is a start

Stop. Caution. Railroad crossing. Flammable. For external use only. These are just some of the warnings designed to alert and protect people from potential danger. Warning signs in the dental business are often insidious. Regardless of whether the signs are apparent, the business leader/owner's responsibility is to protect the business, team, and patients.

When was the last time you identified your vulnerability in the following areas—data leaks and security breaches, HIPAA, OSHA, malpractice, and human resources compliance? For a more comprehensive risk management list, your insurance company can provide you with a self-assessment. Would your practice pass a risk management evaluation? Self-assessment is a start.

The bottom line

• Identify your vulnerability via a risk assessment.
• Establish a plan and implement the steps to mitigate risk.
• Make sure you have appropriate insurance coverage.
• Reducing risk and protecting your practice is your responsibility.
• You must be proactive to minimize risk. Do not jeopardize your reputation and everything you have worked for. —Nancy Clark Crossin
  
  

Issues result from a lack of training

When we think of a felony, we usually think of something sinister. Yet, dental practices commit felonies every day, they just don’t know it. Most felonies committed in dental practices involve fraud. This is why it is critical for the doctor and team to understand proper coding and billing. Ninety-nine percent of practices that get into trouble have no malicious or fraudulent intent. They get into trouble due to lack of training.

When I perform a risk assessment for a practice, I keep the following three concerns at the forefront.

Supervised neglect: This includes failure to diagnose and treat; allowing a patient or dental benefit plan to dictate treatment (such as performing a “bloody prophy” on a perio patient because the person refuses scaling and root planing); or delaying needed treatment.

Do we allow patients to refuse x-rays for an extended period of time, yet perform procedures? Can we perform a procedure that we know does not address the diagnosis or clinical need of the patient just because the patient signs a refusal? No! We cannot force a patient to follow our diagnosed treatment plan. But to do something less than that can be supervised neglect and well below the standard of care.

The standard of care: There is no actual regulation for “standard of care,” rather, there is a definition and expectation that a reasonable provider with comparable education would make the same decision. We know that oral pathogens contribute to many serious health conditions. Allowing patients to refuse perio treatments, especially those with comorbidities, not only puts the practice at risk, but can seriously jeopardize patients’ health.

Just as undertreating is beneath the standard of care, excessive treatment, such as taking x-rays because a patient is “due” rather than basing the x-rays on clinical need, can also raise a red flag. X-rays must be prescribed by the doctor per individual need.

Documentation: Documentation is what determines if you are defensible. This is where I consistently see the biggest risk.  Some examples are seeing a patient for perio maintenance and billing for a prophy because “it’s covered by their insurance;” making a stayplate and billing as an acrylic partial, placing a base during a crown prep and billing for a crown buildup; and diagnosing treatment but not supporting documentation about x-rays, perio charting, or how you arrived at that diagnosis.

Not only is accurate documentation critical to correct coding, but it can reveal hundreds or thousands of dollars lost—legitimate revenue lost because something was left out. I can sum up documentation in two words: prove it. If something is not in your patient records, that means you didn’t see it, you didn’t say it, you didn’t do it, it didn’t need to be done, and it doesn’t exist!

Do not become too comfortable or assume that you know all the current codes and regulations. A practice risk assessment and team training in the area of risk management is essential to keep you and your practice protected and profitable. —Theresa Sheppard, RDA

Consequences can be huge

Because dentists are in the customer service business, they often “do what they can” to make patients happy. Occasionally a patient will request that the date of service for their care be altered so that the insurance benefit will cover the procedure. Patients ask if the office can change the code of a procedure so that the coverage will exceed what the actual coding will allow for.

In order to make patients happy and let them feel like your practice is going above and beyond for them, they may ask you to consider waiving their deductible or extending a courtesy for the amount due by the subscriber. As tempting as it is to give into patient requests, think of the consequence. Making any changes on an insurance claim or altering accuracy (intentionally or unintentionally) is illegal! There is no alteration. It is either correct or incorrect documentation. Losing a license is not worth taking the chance.

How do we guard against potential insurance fraud?

• Know the laws. Understand your state statutes.
• Educate your team. When they know better, they do better. Lack of knowledge is not an excuse.
• Educate your patients. Their policies describe their benefits. Patients must understand their commitment and obligation to their oral health, and those who are educated make better health-care choices.
• Establish a routine for checking the work of each team member, including insurance claims, electronic claim submittal, insurance adjustments and PPO write-offs, primary and secondary submittals, and charting.

Insurance is one of the beasts that dental professionals must slay. Learn the loops. Understand the process. Get ongoing training. Remember that you’re committing fraud, whether innocently or intentionally, and the consequences can be huge. —Theresa Narantic

Originally posted in 2021 and updated regularly