What You Don't Know Can Hurt You

[0:00] You are listening to the Dental Practice Owner's Podcast, brought to you by Prosperident. From our unique perspective as dentistry's embezzlement experts, Prosperident's team can bring you the information that is important to practice owners. The Dental Practice Owner's Podcast brings you strategies, tools, and tips that you can use and dentistry's thought leaders as guests. So sit back, relax, and listen to Prosperident's Amber Weber, Wendy Askins, and David Harris

[0:31] talk about the issues that matter to you. Well hello everybody, it's been a while but it's great to be back with you. I'm here with my friends who you probably remember from past webinars, I've got Wendy Askins and Amber Weber both joining me tonight. Sheila O'Driscoll, one of our team is off camera but we'll be handling the chat part of tonight. We have Samir Basin from Carecredit and I'll put him on the podium in just a minute.

[1:11] And our very special guest, Dr. Roy Shelber. Oh David, how are you? I am great Roy and I'm so looking forward to what you have to say tonight. Well thank you. I'd like to start by thanking Samir and Carecredit because they have sponsored Roy's presentation tonight.

[1:28] Samir and I are longtime friends and it's really great to have you on the webinar Samir and also making this happen with Roy. And I think tonight you have the job of introducing Roy. Yeah, hey, thank you and good evening everyone. I do believe when David said that tonight's going to be an amazing evening for the people that are in attendance, I think you're in for a lot of learning and a lot of walking away

[1:59] with ideas. Now I want to take you back about eight years ago and we're sitting in a nice restaurant. It was a sit down meeting dinner and I looked to my left and I have a gentleman sitting next to me and they said, what do you do? And I said, well I'm Samir, I work with Carecredit and I get to work with a lot of the experts and the speakers and the consultants and my team helps the doctors in making their dreams

[2:27] and helping the patients. We are here all to serve everybody. We call them patients, we call them card holders but ultimately it's that patient. And I said, what do you do? And he goes, well, you know, that's interesting because I was in prison for 19 months. At first I thought he was joking and the longer the conversation continued, I'm thinking this

[2:51] is the most fascinating conversation I've had and it showed like the whole different aspect of the whole idea, ignorance is bliss, well this would not be one of the cases that I would call that. So Roy and I have had the pleasure of working with him and listening to him and watching him, his story, the lessons he learned, the objective and how he made that, his lifelong passion to help other dentists stay out of jail and I think there's a lot to be said

[3:22] about that. And I'm a personal fan of Roy, I really hope that you will see the side that I get to enjoy. He's funny, he is to the point but he's got amazing stories to tell. So without further ado, yes, care credit, you know, we help practices be profitable, help more patients, but part of being profitable is keeping and keeping that money and saving

[3:51] that money and reinvesting it back into your practice. So between Roy and David's team, I do believe that you have, you should have a very productive evening. So without further ado, Roy Shelderman, I'm your friend, take it away. Thank you, my friend. I'm kind of looking at your background and thinking, are you in the jungle tonight or

[4:12] what's going on? Have you not just not mowed your yard or what's going on? I learned that from you to stay in Cognito. Exactly, I can't tell where you are any time. Samira, thank you, I value your friendship, I value what care credit does for the industry, for speakers, writers and consultants, you're engaged in so many areas of dentistry

[4:33] but your goal is to make sure that our patients are taken care of and as long as we're in that business, we make a difference and that's what we do focus on. Thank you for making that possible in so many people's lives in so many different ways. David, thank you for inviting me. I appreciate that. David and I share this running joke.

[4:52] We introduce ourselves very differently. He puts people in jail and I try to keep them out of jail. A lot of people might run away from and maybe I should, that past that I've had, that experience that I've had but I feel I have been given a calling, a gift if you would to have an opportunity to be able to share my story. My passion is that I am the last dental professional who goes to prison for things that they didn't

[5:19] know or understand. I always thought if I had received anything that I wasn't entitled to, I could return it with any interest or penalties that were involved. The best offer I ever got to settle prior to going to trial was three years in prison and a restitution of $300,000. So that was the best offer I had.

[5:40] I was a big city junkie, loved going to meetings. I'm in a very rural area, it's very isolated so I loved the opportunity to be able to go to large dental meetings, talk with my colleagues, learn and grow and I had flown from the western part of Virginia to San Francisco, California. It was 2003, the American Dental Association meeting there. Rudolph Giuliani was the keynote speaker.

[6:04] This was two years after 9-11, he was speaking on leadership and I was listening intently to what he was saying and I was so into what he was saying that when my phone began to vibrate in my pocket, I didn't notice and the person next to me did and they elbowed me and said, I think your phone's vibrate. So I opened my phone and it identified that my wife was calling. She didn't go with me.

[6:26] She was actually visiting my daughter who was at Virginia Tech at the time. So she wasn't home and I thought that was weird that she called. She probably knew I was in a meeting so I thought it was a mistake. So I folded up my phone and I waited for that session to end and as everybody poured out of that large auditorium, I called my wife and it rang four times and it seemed like somebody picked up but that nobody was speaking on the other end.

[6:51] And if you know my wife, she is a great lady, great conversation, she's usually at least two words into the sentence by the time the phone connects and the silence on the other end made me think it may have dropped the call. So I said, Debbie, are you there? And she said, Roy, I am. Are you sitting down?

[7:08] Have you ever gotten a phone call like that when you knew what was coming next was not going to be very good? That was one of those calls. I said, Debbie, do I need to be sitting down? She said, well, you absolutely do. I said, Debbie, what's up?

[7:21] She said, James called. James was our custodian. James called her to let her know that the FBI had come to my office, had battered down the back door and were taking all my records. That was not a good day. Took a deep breath and mind-spinning 90 miles an hour was trying to figure out

[7:37] what in the world, had a conversation with her for a while, trying to reassure that things were going to be okay. Had no idea what was going on, but it had to been a mistake. And so I hung up the phone, now sitting in this auditorium in California, kind of by myself, and I was trying to figure out what in the world I was going to do.

[7:54] So I called my office. It was a Friday. My team wasn't going to be there. I didn't expect anybody to answer the phone, but two rings and somebody on the other end went, hello? And I said, hello, who is this?

[8:06] Boys on the other end said, who's this? I said, I'm Dr. Shelburne. I own the practice you're in and the phone you're talking on. Can you tell me what's going on? He introduced himself as an FBI agent. He said, he told me, he said, sir, you are the target of a healthcare fraud

[8:23] investigation. I said, what is this about? And to this day, his response still kind of puts a chill at my spine. He said, doctor, you know what this is about. I said, I have no idea. Do I need an attorney?

[8:37] He said, I can't advise you. Do I need to be there? He said, no, you don't. I hung up the phone, went back to my hotel, packed up my belongings, went to the airport. Luckily there was a seat open on a flight home, got home at about 9.30 that

[8:51] evening, drove past my office, and it was surrounded by crime scene tape. With multiple black FBI vehicles, and I parked across the street and I watched them carry boxes out of my office into their vehicles. Went home, called my team. I asked, did anybody know what was going on, and they had no idea. That search and seizure happened on Friday.

[9:11] Our county's fall festival was the next day. There were parades through town, there were booths set up on the side of the highway, and guess what the talk of conversation was? Some of my practice in my grandfather's hardware store building. It was in the largest town in accounting. The population of the town was 1,800.

[9:28] That's 1-800, so very small, very rural. That was my grandfather's hardware store building. I treated my family, my friends, neighbors, and it was kind of shocking. I was under investigation for the next three years. No stone was left unturned. In fact, three teams of officers went simultaneously to my three children's

[9:46] universities, flashed their badge to the professor in the class, stopped the class and said, we need to interview these students. They pulled my children out of their classroom and into an empty classroom and interrogated them anywhere from three quarters of an hour to two hours. As a parent, that did something to me. I actually asked them to come home and I said, I can't stand this.

[10:13] I can't stand to watch this affect you, so I'm going to plead guilty. And my daughter stood up with her finger in my face and she said, Dad, if you do that, I'll never forgive you. And the other two said, we're fine, we're going to make this. If you plead guilty, it says that you're doing something that you didn't do, so don't do that.

[10:30] We're fine, we'll make this work. And before we end tonight, maybe I'll share with you how that ended up. But trial was October the 26th that began, or I was indicted October 26th of 2006. I was charged with health care fraud, racketeering, money laundering, and structuring. Trial was in March, or excuse me, February of 2008, longest nine days of my life. But all this to say, I have learned a lot in the process.

[11:03] In the investigation, preparing for the trial and subsequently, I've become an expert on delocating billing and documentation because I feel it's necessary that everybody needs to know what they need to know to stay out of trouble. I'm a recognized American Dental Association subject matter expert. Now I lost my license, was able to reapply after three years. Virginia, the minimum period of revocation, three years.

[11:25] My license has been restored, and I've been blessed to be able to share the story hoping that I'll be the last one that is affected by what went on. So as far as moving this forward, David, there you go. It might not be working, so I'll ask you to do that. Disclaimer to begin with. A lot of the advice I'm going to be giving you has legal repercussions. I'm not an attorney. What I've learned, however, in the process, I have a PhD in

[11:56] what not to do and hopefully insights on what you can do. And my goal is to maximize your legitimate reimbursement, get every penny that you're entitled to from the insurance companies, minimize risk, and I want to keep down a prison. There are things that you need to know that typically when I lecture, there are a number of people in the audience that are unaware of a lot of the instances that can get you into hot water. So what I'm sharing with you is as a

[12:24] person who has experienced it, I'm not an attorney, so just be aware of that. David, go ahead and move on next, please. There are a lot of speakers who say they don't want to scare you. I'm not that guy. I want to terrify you, but I also want to give you the tips and tools you need. If you implement them, then you don't have to be fearful. You only need to be afraid if you bury your head in the sand and you aren't aware and

[12:47] don't implement things to be able to protect and defend you. There are ways to be able to systemize that. This is my crew. This is my family. This actually was taken the year after I was released from prison in 2010. The American Dental Association meeting that year was in Orlando, Florida, and they have the not so scary Halloween party, where grown-ups can dress up and have a good time. That's me in the back. I'm dressed as a pirate. I wanted to go as a convict, but my family wouldn't let me. They told me that that was

[13:13] too obvious. I shouldn't do that, but am I proud of what I've been through? Absolutely, I'm not, but I am also not going to hide from it because there are a lot of people who do hide if there's something that like this has happened. I've had several dentists who have had brushes that nobody knows after a lecture. I can lecture, and then the week later, somebody would call me and said, I need to get this off my chest, and they share an experience they've had. With what went on with me, is it more prevalent

[13:45] than you would think? Yes, it is. Ultimately, I want you to concentrate on who you are. It would be a bit of a waste of time if we just talked about billing and coding and not talk about something that is intimately important. That's what's within you. And I want to share this quote, what lies behind us and what lies before us are tiny matters compared to what lies within us. All individuals have a strength and a joy and a love that they need to tap into. And in today's world, we need to do it more

[14:17] often than ever. We need to be a beacon of positivity when there's so much negativity. The world is only going to change if we step out of our comfort zone and help to encourage positive change. So I encourage you to do that every day in your practice. Is it happy, happy, flowers, joy? All the time, absolutely not. There are all kinds of challenges, but focus on the 90% that is great. There's always going to be that 10% that will capture your attention and make you think negatively when, in fact, the majority

[14:50] of what we experience is much better. I want to share with you this in the beginning, one of the major misconceptions I had regarding what's considered fraud. Now, I knew in the dental world if you billed for a service you never did on a patient you never saw intentionally, that would be considered healthcare fraud. But what I didn't understand is the law from a legal standpoint, the definition of intent is much greater. It includes what's called blind disregard, which means if you do the same thing the same way without having systems to identify and correct

[15:27] errors, the errors that you make if you don't have that system can be construed as intent to defraud. You're just burying your head in the sand, you're not paying attention when you're supposed to to identify and correct errors. So is there anything, is there any such thing as ignorance is an excuse? Sameer, thank you for sharing that in the beginning. It absolutely will not cover you. For example, HIPAA or OSHA, if you say, well, I just didn't understand the rules, are you going to escape that action that they're going to take against you because you

[16:03] buried your head in the sand? And no, no, same thing with billing and coding, that claim that you send into the insurance company is a legal document. And you attest at the bottom of that, doctors, by signing that, however the signature is placed on that claim form, is that everything is correct and right on that claim form. So you are attesting that you have reviewed that for accuracy and that you are attesting to the fact that it is accurate and correct in all its aspects. This slide I'm sharing with you right now is from a slide deck

[16:32] that the government uses to teach doctors and dentists some of the potholes that you can run through. And this is specifically about the False Claims Act. And it states there in red, no specific intent to the fraud is required. The False Claim Act defines knowing to include not only actual knowledge but also instances in which the person acted in deliberate ignorance or reckless disregard for the truth or falsity of the information. Just saying that if you don't pay attention, if you don't have a system to

[17:03] identify and correct those errors, you can be held accountable and can be, that can be construed as intent to the fraud. And in fact, if you see Medicare, Medicaid, federal employees, dependent of active duty military, anybody who is covered by the Affordable Health Care Act, all those to some degree are reimbursed by government funds. If you accept any of those, there is a mandatory seven step compliance program that you need to follow in order to be compliant. In the toolkit that I've provided you, I think you have a link that be shared with

[17:40] you. If you click on that, that's one of the documents that will be shared. It outlines the seven step compliance program. You should look at that. And even if you aren't accepting any government funding or a government reimbursement, it's a good idea to be able to implement that. So you do identify and correct the errors and it will help you moving forward, staying out of harm's way. So let's talk about in dentistry today, what are some of the more common fraudulent acts? The first one is the obvious one I talked about before,

[18:08] billing for services, procedures and supplies that were never provided or performed. That's billing for a crown you never did on the patient you never saw. But it also includes intentionally misrepresenting. We talked about intent before. So if you make a mistake, it can be considered intent. End of the following from the purposes of obtaining a payment or greater payment to which one is not entitled. The nature of services, procedures and supplies performed are provided. That's up coding. For example, you're doing

[18:38] a partial on a patient that partial is acrylic and rot wire. And you bill for a cast and acrylic partial. You did a partial for the patient. However, the code that you use is one that is reimbursed at a higher rate and it doesn't accurately reflect that service that you provided. Same thing goes for crowns. If you bill for a porcelain crown when you did a base metal crown or any time that you it's being billed at a higher rate or at a using a code that's reimbursed at a higher rate, that can be considered a fraudulent submission.

[19:16] Next one, date on which services and our treatments were rendered. And we can't raise our hands here. Well, you can raise the hand button if you'd like to. How many of you have had a patient ask you to commit healthcare fraud? For example, it's near the end of the year and they have done work that they know that they need. And the benefit for that year is only going to be good until the end of the year. And they don't want to lose that benefit. So they ask you to go ahead and can you go ahead and bill that now? So I get benefit of that.

[19:44] Or in the event that the patient has used their maximum for the year and they need something else done and they want you to hold that claim for that service that goes over that date till the next year so that they will roll over as far as the annual maximum goes. And I need to out myself here. I have ADHD and I chase rabbits. I'm going to chase a rabbit here. Why has the annual maximum on insurance plans changed? Never. There is a reason. So of all the individuals with dental insurance in the United States, what percentage of them

[20:25] actually hit that maximum? So of all the thousands and thousands of individuals with insurance in the U.S., how many of them actually use that $1,000, $1,500, $2,000 maximum? The answer is 7%. And the insurance companies look at that and go, only 7% of our insured use that. So why do we need to raise that maximum? David, it went forward. One, could you go back back up one more? Thank you, sir. Medical Record of Service Intertreatment provided. Make sure that your clinical documentation is accurate and it does reflect exactly what you

[21:02] did. Don't play with the documentation in order to justify a higher reimbursement. The condition treated and the diagnosis may. So before anything is treated, make sure there is a diagnosis that precedes it and the treatment will directly track from the diagnosis. For example, a complete periodontal diagnosis will have three variables. It's either mild, moderate, severe. Second set of variables is generalized or localized. Third variables is chronic or acute. So a complete periodontal diagnosis would be chronic, generalized, severe periodontal disease.

[21:44] Unfortunately, in most cases, I will see a period chart which suggests that there is an issue. I'll see the x-rays there. Those will also suggest there is an issue, but the clinical documentation does not list a diagnosis. In medicine because reimbursement is diagnosis driven, you'll always see a diagnosis in a medical clinical record. Dentistry, not so much. So be aware that's part of your documentation and honestly, documentation is the foundation of everything in the dental office in terms of reimbursement, in terms of patient care.

[22:22] If you give that person who is doing the insurance billing the information they need, it streamlines the process and it will very greatly increase the chances of it, that claim being paid first time without delay or denial. Give the people the information they need to be able to bill appropriately. Make sure it's accurate. Make sure that it does accurately reflect what was done and that anybody who looks at that can read the story. It has a beginning, a middle, an end. Leave nothing out. Leave nothing to question and

[22:53] you will keep yourself out of harm's way that way. The charges for services, procedures, and supplies provided are performed. Here again, I'm going to go back to the fact that that claim that you're submitting is illegal documents and the fee that's listed on the fee side should be the fee that you have agreed with a patient to accept as payment and full. I'll say that again. The fee that is listed on the claim form should be the fee that you've agreed with a patient to accept as payment and full. If you're giving any discount, the discounted fee

[23:23] goes on the claim form. I recommend even if you're in a PPO, use your regular fee schedule when you bill those out so that in the event that the insurance company does an evaluation of the reimbursement percentages, they'll have an accurate view of what is actually charged by your office. If you write off down to the fee schedule, when the insurance company reviews the fee submissions, they're going to look at that and go, they pay 100% of your fee. So why in the world would they need to raise it? Also, if you have multiple plans as far as coordination of

[23:57] benefits, you may lose out the ability to be able to collect more than the least amount. That's a whole other lecture on how to be able to write off with multiple plans, but like I said, I encourage you to use your full fee. This next one comes into play a little bit more today than it did 15, 20 years ago, because there are a number of associates coming and going and practices today. That claim form should accurately identify the provider of service on the line. That doctor who did the service or supervised the team member that did the service,

[24:30] that's the name that goes on the bottom right hand side as provider of service. It would be inappropriate to use anybody else's name on that line. And the reason why that comes into play is especially in-network, out-of-network, it doesn't matter if that doctor's in-network or out-of-network. You don't choose who you indicate provided the treatment based on how it's going to be reimbursed. You base the name on that claim form based on who provided the treatment to do otherwise would be considered fraudulent. And I also encourage you to identify

[25:03] the patient. In today's world, people can trade their insurance cards and somebody could use it inappropriately. And in the event that it's discovered that the wrong person used that card, generally the person who does the reimbursement to the insurance company once they find that out is the dental practice. You are responsible for identifying the person who's using that card as the person who is actually authorized to use that card. So be careful about monitoring and making sure that the right person is using the card who is presented and the deliberate

[25:34] performance of medically unnecessary services for the purposes of financial gain. There again, it's going to be important that you determine medical necessity, the diagnosis, the reason why the treatment is being recommended, and be careful. For example, are cosmetic services reimbursed by insurance company? No, it's considered medically unnecessary. It is a cosmetic service and dental insurance does not cover cosmetic services. And here's a little boogaboo that might come into play. So a patient comes in, they have a diastema between their

[26:13] centrals between eight and nine, and they want the diastema closed. They want to use a composite bonding technique to be able to do that. So the doctor does that, closes on one side and the other so that there's no gap there. The code that would best describe that closure of the diastema more than likely is going to be a D2335 composite involving four more surfaces and or the incisal angle. That would be the correct code to describe it. However, closing that diastema would be a cosmetic service. So if you load that in your treatment plan and list that in the

[26:51] appointment schedule, that that's going to be done today, and you don't disclose that to the person who's doing the billing that it is a cosmetic service, that person will get that information, MODF or MIFL or whatever you want to describe those closures on eight and nine. They look at that and go, oh, that's a composite restoration. They load that in on a claim form. They fire it off the insurance and you have asked the insurance company to pay for a cosmetic service. And knowing that the insurance will not pay for a cosmetic service, they pay it. You've accepted

[27:22] it. You have deposited it in your account. You haven't disclosed that it was cosmetic. To the insurance carrier, you would be guilty of healthcare fraud. So typically at this point, I ask people to raise their hand. Do they want to quit dentistry and do something else that's not so deadly? I don't. Like I said, it's just a matter of learning, growing and making corrections as necessary. Okay, David, my advance is not working again. Sorry, I worked for a minute. Thank you.

[27:53] Has COVID changed things in our lives today? If you say no, I don't know where you've been living. And I have, I've been a fan of this quote ever since I was released in prison. Abandon the road is only the end of the road unless you fail to make the term. You know, I thought I would be my dental practice going this direction until I got to the point I was so old, I couldn't hold an instrument anymore. So see not, I couldn't figure out what I was doing because I loved it. I loved every single moment of it.

[28:27] And fate had a different, different road for me. Instead of going this direction, I went totally 90 degrees or maybe 180 degrees in the other area. And to be honest with you, there were hard days. How do I make this work? How do I go on? I just remember thinking there are other things that are more important. Those are the relationships with my family, with the people that I care about, with the friends, even taking care of my patients. There were some days in that three years I was under investigation in the year and a half before

[29:02] I went to prison or went to trial. It was hard some days. But to be honest with you, people will surprise you. The best year I ever had financially was the year after I was indicted and the year before I was prosecuted. That was about a year and a half. We produce more in that period than we ever did prior to that. You know how your diagnosed treatment that patients need, a crown or parcel or something like that and that postponement, whatever reason. That whole year and a half they would come in my practice,

[29:33] they would sit in my chair and I would go there again. I said, you know, this tooth on the upper right-hand side, it's in really bad shape and it's continuing to deteriorate. I don't want you to lose it. You really need that crown. And the patient would typically go, yeah, I know, Doc. I know I need it. And I want you to do it. And they would look back in the chair. They'd kind of roll back like this and go, and I don't know if you're going to be here and not so do it now.

[29:57] They say any publicity is good publicity. I'm here to tell you. I wouldn't recommend it. But honestly, if you have developed a relationship with your patients, they know who you are and they trust you regardless of what anybody else says, you cannot break your practice. So take home to you. Think about that. Is that the practice you'd like to have? Hopefully that is the case. That's you moving forward. That's something that you focus on. David, go ahead and help me forward.

[30:25] So lived in the middle of nowhere as I told you. One of the five poorest counties in the state during the period of investigation, depending on the year, as far from Richmond as you possibly could be and still live in the state. I actually am west of West Virginia. I live in Virginia, but I'm west of closer to six other state capitals and I am Richmond. So I am literally in the middle of nowhere in a town of 1800 population of the county is about 18,000. And if you think you're isolated and nobody knows what you're doing,

[31:00] that is wrong. In today's world, every insurance company shares submission information with P and O strategies. That company actually crunches all the numbers, put together a bell curve of averages so that they profile every practice and every doctor within this bell curve of normal. So practice average, doctor average is in the middle of the bell curve. If you do more of a particular service than your neighbor or anybody else in the state or anybody else in the country, depending on how many more procedures you do, the further,

[31:36] the more you do the further out to the right on this graph you go. So if you're one standard deviation, that means you probably do 20% more. If there's another standard deviation, you do 40% more. And if you're that lone person on the right hand side, you do so much more that you're standing out there by yourself. So you are being audited constantly. And in my experience, although they say this audit is random, there's no such thing as a random audit that I've ever seen. It's always been triggered by something. For example, general dentist, the number of surgical

[32:09] extractions as opposed to simple extractions, covers right in the neighborhood of 25 to 30% surgical as opposed to simple. As far as core buildups, they know that number. As far as regular restorations, the most frequent is the single surface. And it goes chronologically down from one to four surface as far as the frequency. So most practices do more one surface, then more two surface, then three surface, then four surface have come in. So if there's something caddywampus in that, that number of frequency of submissions, it puts up a little red flag

[32:47] with them. And they go, hmm, I wonder what's going on. And that might trigger a letter that says you do more crowns than your colleagues in a particular area. Of course, I've never seen a letter to a doctor that says you do to few crowns, you need to do few more of those, but I've never seen one of those. Maybe there is. If there's somebody out there that's got one of those, please share that with me. That would be good for a laugh. But just know that in the event that you get one of those, it doesn't mean a whole lot. And I would encourage you to respond,

[33:16] even though you're not supposed to, I would reach out to the dental director and say, yeah, I got this letter. I want to make sure I'm compliant. It concerns me that I might be doing something inappropriate with my submissions. Can you help me understand? And what that does is it tells to that insurance company, and are they more than just machines? Yes, there are people that work there that you're concerned and you're trying to be forthcoming and to do it the right way. I always encourage you to reach out to at least attempt to get

[33:44] that conversation going. And if you are doing something inappropriate or if you're misusing the code, learn from it, grow from it and make that change. And it's always good to keep a log in your practice when you adopt new trends or new systems in your practice so that people could look and go, okay, they found out that they were making this error and look what they did to be able to correct that. So that's a great way to be able to do that. Go ahead, David. Move on forward, please. Thank you. And let's talk a little bit in today's world.

[34:18] What are the codes that the insurance companies are looking at? And I go to both the National Association of Dental Plans and the American Academy of Dental Consultants. Those are the consultants that work for the insurance company. They review your claims. So I'm a member of that organization. Go to their meetings. And I hear a lot of conversations about what they believe the codes and the services that are being maybe abused in dentistry. And these are the ones that they're looking at. The 43-41, the Paradolal Scaling and Replaying,

[34:46] four more teeth per quadrant. So as far as to justify the scaling and re-planning, three things need to happen. There needs to be bleeding on probing. There needs to be attachment and pocketing. Four millimeters are greater. And that threshold is different with different insurances. It may be four millimeters or greater. It may be five millimeters or greater. And the radiographs should show at least 10% bone loss. And standard of care for a radiographic assay to substantiate and to document the need for scaling and re-planning

[35:19] as a full mouse series. So if you're doing bite wings and a panorax and you're having those claims denied or they're asking for more information, that may be the reason. So number one, periodontal charting that's complete that show the bleeding on probing, the x-rays that show bone loss, the periodontal probing four or five millimeters or greater. And photographs are also helpful. A lot of times with soft tissue issues, it doesn't show up on an x-ray. So a picture is worth a thousand words. Support it with

[35:48] photographs. So 43-41 justified that way. If there is no bone loss, if they do have pocketing five millimeters greater bleeding on probing, but not 10% bone loss, that's probably going to be a 43-46. That's going to be scaling in the presence of generalized moderate to severe inflammation. And as far as from the American Association of Periodontology, generalized is anything 30% or more. It's also a great idea to take pictures with those because you can see the gingival inflammation where you may not be able to see

[36:21] it on a radiograph. So those are very supportive. Next is alternating the prophy and the periodal maintenance. Pam Throw is a good friend of mine. She actually does the insurance billing and coding support for the American Association of Periodontology, the periodontists. And of course, they establish the standard of care. And if you ever entertain a question about alternating between the prophy and the periodontal maintenance, she will get up on the chair and will scream to the rafters, that is not possible.

[36:51] A patient cannot have gingivitis, no periodontal disease, then periodontal disease. Because we talked about earlier treatment is driven from the diagnosis. So if it's inflammation, that's gingivitis. If it's bone loss and pocketing, then that is periodontal disease. Periodontal disease has periodontal maintenance. Gingivitis has either the 4346 or the prophy. Very clear. The core buildups 2950, this is a magic word kind of thing. Magic word as far as justification for the core buildup is

[37:20] retention. Without the core buildup, the tooth would not be capable of retaining the crown because there's just not enough structure there. So as far as documentation for that, it's good to have pretreatment x-rays, pretreatment photos. Then once all the faulty restorative material, all the decay is removed, you're ready to do the buildup. It's a good time to pull back, take a picture at that point, and include all that to the insurance company. Now, if a plan and several plans have adopted the policy that they're not going to pay for

[37:52] core buildup separate from the crown, that being the case, it's a policy issue. Will you ever be able to give them enough documentation or a narrative to get them to change their mind? The answer to that is absolutely not. You never will because the plan just doesn't cover that. Surgical extraction as opposed to a simple extraction. Surgical extractions, one or two things need to happen. Both of them can happen, but at least one of these two things. The tooth had to be sectioned because the

[38:16] morphology was such that you couldn't get a way of being able to get it out because the roots were dilacirated or if they were convergent. So tooth had to be sectioned to get out or bone needed to be removed or both those things. The documentation both in the clinical record and on the claim should support that. The 2391 resin-based composite 1 surface, and this is the insurance protocol. If that conservative restoration on the flusal of a posterior tooth does not go into dentin, from their point of view,

[38:48] it is not a restoration. It is a preventive resin restoration of 1352. So just from their point of view, I'm saying that's what they developed as an industry or accepted. We talked about this when the 2335 resin-based composite 4 or more surfaces is a modeling sizeal angle anterior. Make sure that it is necessary because the tooth is either decayed, the tooth is fractured. If there's a faulty restoration, then that's medically necessary to close the diastema. Unless I'll give you the one caveat, if the diastema is causing a periodal

[39:21] issue packing in between, you might be able to justify the restoration that way from a medical point of view. It's going to be a hard sell to the insurance company, but that would be the only one way that you would consider it medically necessary and not cosmetic. X-rays, big deal. Number one, they need to be medically necessary. And in your toolbox, I included a document that the American Dental Association and the FDA came together in 2008. They updated it in 2012. I think it's 17 pages that include how you go about determining when radiographs are necessary.

[39:56] And it even has a grid. Patients age some of the risk factors and there's a box there, which standard of care would suggest that. Now, is that safe? Do you have to do it that way? No. Whatever you as the doctor determine is in the best interest of patient and what you need to be able to move forward, you do that, but always make note of why the x-rays taken. Number two, make sure that it is clinically acceptable. If you bill for a clinically unacceptable radiograph, when it wouldn't pass a proficiency in dental school, hygiene school,

[40:25] assistant school, you've billed for a worthless film, a worthless service, and that could be construed as a fraudulent submission. So they need to be standard of care. And the third thing that needs to be in the clinical record is the notation that the doctor read them. That closes the door. So all three of those are taken into consideration. Next one, David. Thank you, sir. Things that I know and I wish I'd known then, a wise man learns from his mistakes, a wiser man learns from another's and I'm the other.

[40:55] So where does the buck stop? A lot of people say, well, I don't, you know, I'm not responsible for that. I don't do the billing. Doctors, it's always you. Your name is on the signature on that claim form and at the signature on the documentation in the clinical record. So it's always on you. However, team members can be named in actions as well. In Texas, there's an oral surgeon who didn't have an office of his own, actually rotated through different offices in the Dallas, Fort Worth area. They indicted him,

[41:24] they indicted his business manager and his lead assistant and the six doctors who provided space for him. In this particular case, they remove the indictments against the team members in exchange for, wait for it, the testimony against their doctor. And the two or the six doctors who provided space, they dropped the charges against them four weeks before it was to go to trial. I understand they spent an average about $300,000 preparing for the trial. So who won? This doctor was found innocent

[41:54] and now lives in fear that he will be indicted civilly. And oh, by the way, I was indicted, I was in prison for federal charges. I was served with papers before I was released two months that I was also being charged civilly. So just like OJ, you can be charged both ways. So ignorance is no excuse. You reasonably should know the correct way to build code and to document. I didn't know is not a good excuse. Pain is inevitable, suffering is optional. You know, are we going to have things that happen in our lives that are

[42:32] hard? They're challenging, they're painful, absolutely. But if you learn to take them for what they are, understand they don't define who you are and what's happening today, we'll change tomorrow. It's easier to have a positive outlook, to move forward rather than dwelling on what's going on now. I may not have gone where I intended to go, but I think I ended up where I needed to be. And I would have never expected or never thought I'd be speaker or writer consultant. Like I said, I love dentistry. I love being at the chair. I

[43:07] love to learn, but life had a different course of path for me. It set me directly in harm's way because there was somebody that needed to be able to share the information. If we as an industry are ignorant, we will continue to make the same mistakes. If we learn and grow, it's more likely that we will not make those mistakes moving forward. About your documentation, be defensive. If it's not in the patient record, it was not seen, it was not said, it was not heard, it didn't need to be done. It wasn't done. It doesn't

[43:40] exist from a legal perspective. After the fact trying to defend what you did verbally, it's impossible. If it's in the clinical record happening, being captured on the day and the time the patient was there, if it's complete, that record can testify for you. If it's non-existent, it will do nothing. There was an issue. There were 118 instances that the government brought that could be construed as healthcare fraud, and I had to spend every single one of them. One of the issue was about a simple restorative procedure. They had an expert witness that

[44:13] testified if the lesion could not be seen on a radiograph, it probably didn't need to be done. There was a restoration I'd done on a patient that did not show up on the X-ray, but I did diagnose it visually and using an explorer in the operatory. I was asked by my attorney to try to justify how thorough I was to determine the treatment was necessary. I went through the whole litany. I talked about using X-rays, but they don't always show the lesions. We can use transillumination. We can use visual cues. We can use explorer soft teeth or unhealthy teeth.

[44:47] I went through the litany of what I did to determine treatment was necessary. Then it was a prosecution's turn to tear apart everything I said, got to this particular instance. He looked at me and he said, doctor, then he flashed, he nodded to his AD person who opened the clinical record for this patient. He said, doctor, you did an amazing job of describing what you typically do to determine treatment's necessary. By the way, if a prosecutor ever compliments you, what comes next is not going to be pretty. This was one of

[45:11] those instances. I said, thank you. He said, flashed, nodded to the AD person. They flashed a copy of the record. He said, so can you tell me for the sake of the jury, show me where it makes note that you did any of those things that you so eloquently described. I said, it's not there. So he turned very dramatically to the jury and said, well, now that we find yourself in this position, we just need to take your word for it now, don't we? And I had taken more care to be able to make a more thorough document that could have testified

[45:43] for me and that one of the 119 would have been off the table. Oh, by the way, about the money, I was paid three and a half million dollars for the services I provided during that six-year investigation period, three and a half million dollars. And that was a large amount. I'll grant you that. County was one of the poorest in the state, so 95% of our patients under 18 had Medicaid, so I had a very busy Medicaid practice. Of the three and a half million dollars, the government determines not the jury, the government determines during sentencing the amount that I got that I

[46:12] wasn't entitled to. Of the three and a half million dollars, the government determined that I got 17,899 dollars and 57 cents. That's less than one tenth of one percent, which I thought was a pretty good error percentage. But the government didn't. So I went to prison for 19 months. I was sentenced to 24 months, but spent 19 federal prison two months and a halfway house to 17,899 dollars and 57 cents. Does it make sense? I don't know, but it is what it is. Remind yourself it's okay not to be perfect. We'll never be perfect.

[46:44] With our billing services, with our documentation service, there will not be a day where we'll be perfect, but we strive for excellence. We need to put things in place to be able to monitor and to grow and to get better. Everybody needs to be meticulous. All the information in the record needs to be clear. It should not be ambiguous. You have to be careful about using acronyms. And I asked this question in a lot of my lectures. What does WNL mean in most dental practices? And the response I get is within normal limits. And my retort is,

[47:18] could it also mean we never looked? So be careful with your acronyms. Have a log in your practice. Use an Excel spreadsheet left-hand side, the acronym right-hand side when you break it down. That's what it is. So everybody's on the same page. And make sure that all the records are signed. Doctors, unless your hygienist is in one of those states where they have an enhancement to their license where they can diagnose, you doctor have to sign the hygiene note as well. The hygienist has to be supervised to the doctor. And here is a very short outline

[47:50] of the seven-step compliance program that I talked about in the beginning. This will be in the document that I shared with you. But number one, you need to start the process of monitoring and auditing. Then you need to establish your standards, what your expectations are in your practice. You need to identify a compliance officer that's the person who's in charge of running the program. They don't do it all themselves, but they make sure that it gets on schedule that you're on track, that you might identify

[48:16] the patients that are going to be audited. Training and education for the team have them understand completely it from the start to the finish what is their part in the process and the expectations of them. If you find issues that you need to improve, you put together systems to make that improvement and to monitor moving forward, lines of communication are always critically important. Doctors, you need to be able to talk to your team. You need to be able to talk to your doctors. If it's not working, if you need something you don't have

[48:46] or expectations, you're confusing. Communications need to be open and finally in the system, if you have someone who has been educated, been given the opportunity to give feedback, to learn, to grow, to understand how the system works and they can't make it work if they just can't meet the expectation. Unfortunately, and I'm not hard, I'm not a hard fast guy, but if they are jeopardizing patient care, the team and the doctor, they do not need to be in the practice. You need to find them another place to work because they don't belong

[49:16] in a dental practice. There's no secret to success. It's a result of preparation hard work and learning from failure and I have learned so much for failure. It's not even funny. So a little bit about getting paid. Enrollment is changing. Delta Dental has reduced reimbursement. Now if you are a PPO doctor and you bring in or you move to a different location, when a change like that, you're no longer PPO or no longer Premier, you're PPO only. There are more restrictions, there are more limitations. Discount plans are coming in.

[49:48] You are in network and they sell you to a discount plan and you didn't know that was even possible. Non-cover benefit legislation, that's something that comes into practice as well, whether or not you can charge your full fee if it's not covered and that's a whole new, that's a whole lecture all day long in coordination of benefits. How many people, the reason I pulled my hair out is trying to figure all this stuff out. It makes it difficult in today's world but I'm not giving you a buy. If you're going to be involved in the process,

[50:13] you need to devote yourself to learning and growing and understand what these are. Finally, pain is temporary, quitting lasts forever. It's one of those things you need to devote yourself to be a constant learner and if plan A didn't work, the alphabet has 25 more letters so be cool. It's all good. Pandemic was horrible, horrible, horrible. However in my family this was Christmas past so I have three children. All three have been married, had been married at least four years, had no grandchildren and during the pandemic in seven months we went from zero

[50:52] grandchildren to three. So is that pretty phenomenal? It absolutely is. I want to leave you with this before we do the Q&A. It's kind of a patient walk into my practice, look like this. This isn't John. John looked like this. I've been graduated for probably about maybe six months and John walked in my practice and dirty coveralls, dirty boots, kind of a torn ragged shirt sat down in my chair and extended my hand. I said, John, how are you and what can we do for you? He said, I'm doing great, a little scared. I don't like Dennis. She said,

[51:26] no offense and I said, well I'd be scared of me too. But he said, I want to have a beautiful, healthy smile and that took me off guard. I didn't expect that from John at all and I said, I'll be happy to try to help you with that and I sit him back in the chair and what I found was as bad as I expected. There was decay, there was some periodontal issues, not too severe but a lot going on, missing teeth and I said, John and I said, John it's going to take me a while to put together a treatment plan for you. Do you mind if I get the

[51:57] records I need and then I'll bring you back in and talk to you about what we can do for you? He said, no, no, I'm fine with that. So I'd worked on this treatment plan for the best part of two weeks and the number at the bottom was scary, terrifying big, especially to a new graduate and I had judged him myself. I thought, well John's not going to be able to pay for that. So let me put together a treatment plan that takes care of some of the disease process that's going on but doesn't suggest ideal care to give him back that beautiful

[52:23] smile and then I looked at that and I said, that's still a lot. How about if I just talk to him about the emergent stuff, the things that are going to be really bad if he doesn't take care in the near future and so I had those three treatment plans. I brought John back and I sat him down and I went through the treatment plan and stumbled over the number at the bottom of that treatment plan because it was huge. And I remember I took in a breath and as I took in that breath John looked at me and said,

[52:48] do you take cash? I said, yeah, John, I do. He said, do you mind if I pay you now? No. So my business manager came back, he counted out the money, she gave him a receipt and he still had a lot of cash in his farmer. They, you know, they did a lot of cash business and had a lot left and he looked at me and he said, thought it'd have been more. I thought, shoot, I missed an opportunity. No, I didn't say that. So we worked for probably two and a half, three months. You have to know John really well. He was a great guy.

[53:25] And I asked him, I said, John, you know, why did you decide to have me do this? And he said, well, son, I'm not a, I'm not a stupid man. I knew your dad, I knew your granddad, I knew you were a smart boy. I knew you were just out of dental school and you knew all the latest techniques to be able to give me that beautiful smile I want, the healthy smile I want. So that's why you, and I said, John, you know, why did you wait till now? And he said, I have a granddaughter. Mama left when she was six month old, don't know who the dad is,

[53:58] still don't. So she's my baby girl. And she's getting married next month and she's asked me to walk her down the aisle. And on that day, I want everybody to know by the smile on my face just how proud and happy I am of her. Oh, would you like to come to the wedding? I said, John, you would, you would never be able to keep me a wedding. That day came and the man that I first met when he walked into my office that spoke with his hand over his mouth and kind of hunched over and a little bit ashamed

[54:31] walked around the corner with this beautiful young lady on his arm and this big smile on his face. And he walked down the aisle. Sorry. And he got to me and he patted his granddaughters, daughters. And he said, hang on just a second. He leaned over to me and he said, Doc, thank you for today. We may have a tendency to forget what we're about. You know, do we fix teeth? Yes. Do we interact with people? Yes. But ultimately at the end of the day, what we do is change lives and make them better. Never lose sight of that.

[55:12] Celebrate what we do. Enjoy what we do. Embrace what we do because we make lives better. We make people better. We make them smile. So if you do that, you'll never be wrong. This is my contact information. If you'd like to reach out, would love to have a conversation. And the cell phone, if you text me, that's probably the easiest way. I'm on the road a lot. I travel a lot. But like I said, I want to be able to respond to you. In this picture, I think maybe a little bit, it's descriptive of what we are in dentistry. We're that

[55:42] fisherman on the surface. We're fishing or working hard to be able to provide for our family. And just underneath the surface, there are a whole plethora of things that can bite us if we're not careful. Just because we don't know they're there doesn't mean that they're not there. So be careful. David, it's been a pleasure to partner with you. And is there an overlap? Yes, I think there are a bit. So you want to talk a little bit about that? I sure do. But before I do that, Roy, first of all, thank you. That was great. And as you

[56:15] were talking, I was getting texts and emails from people saying, wow, this is amazing. Oh, wow. So some some some wonderful feedback. What I want to tell the audience about Roy is this. And you guys know what Wendy and Amber and I do for a day job. We chase criminals and we put them in jail. And what each of us sees happening is when those people get out, a lot of them go back into their old bad habits. And you've heard us, if you're a regular audience member here, you've heard us talk about serial embezzlers and

[56:53] the people who do it over and over again. The champion, as far as I'm concerned, is somebody named Irina who has probably stolen from 15 dental practices, which is a whole other can of worms, Roy, in terms of, you know, how Dennis background check people before they hire them and things like that. But where I'm going with this is the man you just heard speak, who is a very good accomplished speaker and all those things is also one of the finest human beings I've ever met. And when life through him, a curveball that would derail most people,

[57:31] he turned around and used it for good. And I've known Roy since shortly after he got out of prison and watching him rebuild his life has been just wonderful to see and be peripherally involved in. So, you know, he's a fantastic guy and I am so thrilled to know him and so pleased that he could be here with us today. Pleasure is all mine. It's very shared. Yeah, just a great guy. If you ever have a chance to see Roy live, please take it. And I know there are a number of Canadians here. I just want to let you know as far as the

[58:12] documentation piece, it's very important. Malpractice is alive and well in Canada, I'm assuming, as well as submissions. You need to be aware that there are repercussions if you make unwilling, unknowing mistakes. I was going to come back to you. It can't. Absolutely. And sure, you know, I was, as you were speaking, I was kind of watching and what I saw was some of the details are a little bit different, but the court principles are very similar. And I was having an exchange, Roy, when you were talking with

[58:43] a Canadian person who works for one of the DSOs. And I think our consensus was very much that, you know, the fundamentals aren't very different. What I was hoping to do here, though, for a minute or two was just have a discussion about where Roy's world and ours have prospered and converges. And, you know, where clinical fraud and embezzlement, in other words, staff stealing really overlap. And I guess what I saw when we were kind of getting ready to have this conversation today was I've seen a number of cases, and I

[59:22] suspect others on the panel have as well, where a staff member was stealing. And if you're if you're embezzling, there are really two ways you could do it. The first way is you can steal from the doctor. The second way is you can make insurance companies pay out money that they're not supposed to. And you take that. And if I'm a thief, emotionally, the second one's easier because, you know, at some level, unless I'm sociopathic, I'm going to feel some I'm going to feel some pain with stealing from the guy or the gal who works 20 feet away from me all

[1:00:00] day and signs my paychecks. A big insurance company is a lot easier to rationalize the stealing from. So we see a fair bit of false claim submission where it's not the doctor submitting the false claim, it's a staff member. And I've also seen a number of cases where doctors start to go through an experience that's not that different than what happened to Roy, because somebody somewhere is unable to distinguish between where the provider is the culprit and the provider is kind of a co-victim. And Roy, I'd be interested in your

[1:00:37] comments or any experience you've had in this area. Sure. Well, coming to mind is a two-edged sword. You know, hopefully the doctor is not doing intentionally, but if the doctor is doing something a little bit, well, I'm not even going to say a little bit, something a little shady, that opens the floodgate for all the team to do the same thing. And they also have a gun to the doctor's head so the doctor is not able to follow through. So the audits that we talked about doing will help to uncover things like that if they are truly random. So yeah, the same

[1:01:15] thing that could help them improve their documentation billing encodings, it could also help uncover something that they are perhaps not aware of. So the same kind of audit system can be expanded that you do to this area as well. So as far as overlap, any time you're building the insurance company, you need to be aware that regardless of who's doing it, needs to be done correctly. When I take away from this too, and you said words that really resonated with me a little while ago, when you said your clinical notes can testify for you.

[1:01:49] And let's say that somebody is billing for work that isn't done so that they can steal the money.

[1:01:59] What should be able to save the doctor in that case is if their clinical notes, if they can show a clear difference between their clinical notes and what was billed. Because logically, if I'm a dentist and I'm going to commit fraud, I'm going to make my clinical notes reflect what I billed as opposed to what I did. I would never create a visible discrepancy. So if I'm called on the carpet, I'm going to say no, this is what I charted. Clearly if something was billed, it was billed by a rogue staff member and not at my direction

[1:02:32] because I can make the clinical notes say whatever I want them to say. Correct. And if I'm trying to justify a five-service composite filling, then if I really only did a three, I'm going to fix the records. So what you said about protecting yourself from what you do being called into question should also help you hear. Absolutely. Now your documentation is the foundation of any dental practice. The stronger, the more comprehensive, the more accurate your documentation, the less

[1:03:10] likely any of the wheels fall off, whether that be money left on the table that's not billed to the insurance company or follow through to make sure that it was done appropriately or if something was done and you have been very active about capturing all the information, then something comes in, there's an EOB or something that you can't tie it to that. That's a huge red light. Yeah. Amber, Wendy, any thoughts? So this really goes back to one area that I believe in. We tell a lot of our clients

[1:03:42] reports reveal the daily details and we talk mostly about the financial transactions that have occurred. But myself coming from a clinical background, I also feel like for protection and to safeguard against vulnerabilities from both sides, embezzlement and what Roy has experienced, that reveals the details too as a clinician. That documentation, that final end of day report is what is going to reveal what truly happened in the office and what may or may not have been completed correctly.

[1:04:12] Correct. There again, a lot of times you see money left on the table and like it's two side sword, doctors in the middle of a procedure that three surface composite became a four surface. But they post from the appointment and the appointment has the three surface. So the doctor has left the money on the table because the person who is doing the submissions either doesn't have the record or hasn't reviewed it. So it's there again. At the end of the day, the accurate information should be on the clinical

[1:04:49] notes and that should be completed before the patient is ever released to the front desk to make sure that any variations from that treatment plan or whatever was to be posted was updated so that it accurately reflects what was actually done that day. And you're right. As far as the love that Amber, as far as the notes, they tell a story as well. And it's important doctors that you review those periodically just to make sure that if there are areas that don't make sense that you clarify it and follow

[1:05:23] up on and it's an opportunity, opportunity to improve systems. If you find something that's fallen in the crack, don't look at it as a mistake. It's an opportunity. We can fix this so it doesn't happen going forward. So that those 15 surfaces that you left on the table that week, next week, you have a system now to make sure that that doesn't happen anymore. That's a great point. And I hadn't really thought of the fact that a lot of people would be posting from the book appointment as opposed to what happened. It's easier just to go hit one key and

[1:05:55] it posts to and if you're not taking the time to go, oh, that was not a two surface. It was a three surface. We need to correct that before we post it. And it's never a good day when the patient walks out and they pay for the two service composite and then the record comes forward and the corrections made and the patient then is sent a bill for $4.64 cents for their co-pay for that extra portion. And is that ever a happy day for the patient? No. No, it looks like a little bit of a clown show, doesn't it? It does. It does. And actually

[1:06:29] this discussion kind of morphs into one other thing that I've told a lot of dentists. When you look at how treatment gets into practice management software, there was a generation of doctors and Roy, you might have been just a little bit young for this, who started in the old payboard system with paper charts. My practice opened in 1981. I bought one of the first dental computers. It was $85 and I paid an $85, $15,000 for this IBM mini computer. So I was an early adopter. A lot of people cut their teeth, so to speak,

[1:07:12] with paper charts. And there's some percentage of dentists who have never quite gotten comfortable with the concept of entering treatment into the software in the clinical area. So they send a paper chart to the front or maybe some kind of routing slip with what happened. That, in my description, that is a Frankenstein system. Yeah, there's a lot that can go wrong there, isn't there? Yes, there is. So if you are not entering treatment in the clinical area, I hate to say it,

[1:07:45] but you're stuck firmly in 1981 and it's a really good time to look at changing that system. And I'm going to go further. In today's world, they should not only be posting the treatment, they should also be scheduling the patient. Because they're going to know Mrs. Smith has to get up and go to the bathroom three times. She can't swallow her own spit for whatever reason, once she's in the dental office. Somehow their own spit becomes toxic at a certain point. She gags and she needs to come up for air. Now, is she going to need more

[1:08:19] time? Yes. And do people get better out of shape when the schedule gets caddywampus? Yes. So if you give that to the clinical people, they'll have a better idea of how long it's going to take them to do the three restorations on Mrs. Smith than the person who is in the business area. That's not to belittle anybody. But one of the things that I recommend is if there's any aggravation between the clinical staff and the business staff regarding the schedule, I recommend very strongly that they give that responsibility to the clinical team.

[1:08:57] So that way they are the ones who are in charge of their own rounds. And if you screw it up there, there's no one to get out. It's on them. And honestly, they know better about how much time it's going to take for that particular patient. Some are very easy to work on, some are not so. So can they expand and contract it? They absolutely can. Yeah, certainly from the embezzlement side, you make it a lot more challenging for somebody to steal when the treatment gets entered in the clinic area. Because it's almost impossible.

[1:09:28] Because anything that gets entered by another individual, and we're going to, I'm sure you talk about this, anybody who is assigned on to that computer should be the accurate person who is actually sitting there keying that in. You do not share passwords, you do not share anything else. And that, just like the signature at the end of the clinical record, you should be every bit as concerned about having the accurate information in that terminal who's sitting there. Because otherwise you don't know who did it. And you always want to be able to tie it back.

[1:10:00] And here again, opportunity, opportunity, opportunity. It's not something that somebody over the head, it's opportunity to be able to learn and to grow. And anytime you're not meeting expectations rather than having that thing in the back of your head and go, they never do what they're supposed to have that conversation. So, you know, this is what I'm seeing. Can you tell me how that's happening? And give them an opportunity to explain. And if you've not given them the opportunity, the training, whatever that is, then it's on both of you

[1:10:27] to correct it. You're not assuming anything. And when I told you I had ADHD, I took that someplace it probably wasn't supposed to go. Sorry. No, I don't know that you did. All right. Well, maybe we should turn it over to questions because I think we've got a fair number. Wendy, do you want to start us off? Do you have one of the questions you want to pass to Dr. Shelburne? Do. Roy, you covered it already. But if you want to add anything to the question, someone asked or managers or billers subject to the same risk of false claims

[1:11:06] or only the owner of the business. Anybody who touched that, racketeering and money laundering are considered a scheme that a group of individuals come together and perform a service in order to be able to get more from that entity than they are entitled to. So they can name everybody from the doctor to the custodian if they wanted to. Anybody who got a check from the practice can benefit from the proceeds. So nobody's immune. In most cases, they don't come after team unless they are principal. If they are part of the scheme who are actively working it to make it

[1:11:36] happen, then yes, they're more culpable. But what generally I see the government will or the acting entity will take action against team members in an effort, just like the one I described, to have them become state witness and to throw the doctor under the bus. Thank you. Another one, another question is the example that you used about closing the diastema. Someone wanted to know if it's a cosmetic procedure, do you write that on the claim form? Do you do a narrative on it? What I would do is develop an in-office

[1:12:22] proprietary code, so it would be 235.2, whatever that might be, and that would identify a cosmetic closure. And that would not get submitted to the insurance knowing that it is not it's not going to be paid. If it's one of the plans that requires everything be submitted to them, I would in the remarks section identify that that was a cosmetic closure, that it was not medically necessary. So if you disclose it that way, if it's auto-inducated sometimes that flies under the radar and that could cause some issues. If that person who's billing it

[1:12:59] knowingly goes, okay, this is a filling, nobody's going to review this, I'm going to put the remarks section, nobody's going to look at that, so we really haven't disclosed it. If you want to be very active, making sure that you don't make a mistake, but still adhering to that insurance protocol that cosmetic is not paid, I would send that as a paper claim with a remarks section on it or send it separately with an attachment, those automatically get kicked out and reviewed. So a live person would look at that and go, okay, understand we shouldn't reimburse this.

[1:13:34] Okay, Amber? One of the questions was if you have under practice for several years, for example, five to six years, and you've had a lot of staff changes completing your administration and billing part, how do you go back and correct issues if they happened, or should you just leave it alone? I would in the practice log identify that the issue was found, we're unaware of it in the past, but this is what you've done moving forward to make sure that never happens again. So I draw that line in the sand and you'll have a record

[1:14:11] of the fact that you did identify it, and as soon as you did, you took corrective action. Okay. Statue of limitation on fraud is seven years, so they technically could go back. However, if you, in the cases that I've been aware of, if you make where they've made a very specific change of action to make sure that it doesn't happen anymore, they don't take action. They may ask for some money back, but they're not going to do anything, you know, aggressive. Okay. Another question was if a practice has an associate, and you're waiting

[1:14:49] for that associate to be credentialed under the insurance that the actual practice is in network with, is it fraudulent to bill under the practice ID until that associate is credentialed? Yes. Okay, someone wrote with regard to zero. I'm going to back up just a second. In some instances, insurance companies will allow, will make a, for example, a local tennis. If they have a application in hand and they're notified that this new dentist is waiting credentialing, some insurance companies will allow temporary credentialing pending the process of the

[1:15:32] application, but don't assume. Always find out if that's the case, and if that's the case, then disclose it. Otherwise, you need to disclose the doctor who actually provided the care and they, they'll process the claim. They'll just be processed out of network. It's not like they won't pay it. They'll pay it under the terms of being out of network. I'm sorry. I thought I should add that. Okay, so someone wants to know regarding zero charge services, if they, they put it in the clinical notes when they did that day, they document it there.

[1:16:03] Should they also document it on the ledger or patient's account to support the clinical notes? I would just to make sure that I'm tracked so that if there's ever a question, it's here and here. And also if there's, if there is the requirement from the insurance company that everything be submitted, it should be there as well. So it's just a matter of making the clinical record meet the ledger. They should also always reflect one another. The service that was provided even at zero, I would list it there as well. Okay. And someone wants to know who brought civil

[1:16:38] action against you and why? That was the same government because they weren't happy with the result. I ended up, I didn't have anything left. They actually, you know, I lost everything they owned. So I met with the attorney once I was released from prison. I said, you know, how much I have more than I do, you know what the bottom line is? I have this amount of money left in my life. You can have it. And if you'll settle it, but otherwise, if you want to go to court, that's fine. You know, I can represent myself. But if you want to go the expense,

[1:17:12] and by that time, I won't have anything left, you'll get nothing. Which would you rather have? So they took the money and ran. Okay. And what recommendations do you have for the doctor to review his or her daily report for accuracy? Which, which report would you recommend? Well, there are several from, I'm just going to tell you as far as from my point of view, the, the doctor from the billing piece, I wouldn't. It's going to be not time. It wouldn't be a good use of the doctor's time to review them all. There should be

[1:17:49] somebody on the team that reviews the clinical record to the submissions. But the doctor should, at random, maybe do two a day to make sure, well, number one needs to make sure that all the, the notes are signed. And there should be somebody that's reviewing that whoever's posting should make sure that the record is signed. If not, they need to toss that back to the doctor so the doctor can sign it. And I'm also a proponent that the doctor don't do their own notes, that the team is trained to do that. They do that for the doctor. Now the doctor reviews

[1:18:19] them and make sure that they are complete. But the best use of the doctor's time is chair side providing care or education to patients. So there's a system to be able to put it in place and using templates to make that. So it's very effective. But doctors should read and sign to make sure that that's all accurate. And then look at the, maybe two, three patients a day to make sure that swats being posted to the patient on that day is correct. And to be honest with you that will alert that person who is responsible for doing

[1:18:47] that, that they better do it right because more than likely it will be found at a certain point if they aren't being diligent about that. So it's as much perception as it is a necessity. And what happens if you purchase a practice in which they are committing insurance fraud of some sort? What's the liability of the new owner for the previous owner's actions? There is none unless you, in the purchase contract, you're receiving any of the outstanding insurance funds that were gained inappropriately. If that goes into your bank account you can be

[1:19:24] responsible for. If you draw a line and accept nothing but what you've built for correctly, you're in good stead. And here this is, I'm going to back this up a little bit as well, which I would never recommend anybody buy a practice unless they have a forensic audit of the billing and coding portion of the practice because that could have a huge impact on the value of that practice. So I did a pre-purchase for a doctor and the owner doctor was probably billing about 15% more than he was entitled to, which means the income for that practice would be

[1:20:03] 15% lower than it was what would be appropriate. And they were able to back out of the purchase because they found that just didn't want to deal with it. So that's something a lot of people will overlook. They think, okay, I'm buying a practice. Everything's going to be done properly. I don't have to worry about it. I can hit the ground running moving forward. You'd be surprised the impropriety as far as the billing coding services that are discovered once the new purchaser walks into the practice and goes, oh, good golly. How did you bill for that? Why did you,

[1:20:34] how did that get back? Roy, that's a great point. And I'll give you a really good example of that. One thing if you're buying a practice that you've got to find out is whether the former owner or the person selling to you was failing to collect co-payments. If that is happening in a practice that you buy and you don't find out till after you buy, you're in this horrible position because you either perpetuate what the last person was doing, which I'm sure Roy would agree is fraudulent. You either keep doing it or you create a patient

[1:21:08] revolt when all your patients suddenly find out that dentistry actually costs money. Now, a failure to collect co-pays and deductibles illegal in every state and considered unethical by the American Dental Association. Yeah, there's no gray area there. So, if the person you're buying from is not doing that, which is something I can tell you we see a fair amount of, if that is what is happening, you can still buy the practice, but you have to know about this and you have to understand what's going to happen to the practice numbers when you start

[1:21:42] trying to collect co-pays that the former dentist never did. It will have an extreme impact on that practice moving forward and as far as just goodwill with the patients, that's going to be out the window immediately. You're going to have to start rebuilding that relationship because either they're going to site with the other doctors and I love my old doctor. He'd never do anything wrong to, okay, my old doctor's been committing insurance fraud all this time and I didn't know what I knew now. So, that's a can of worms you really don't want to

[1:22:14] find yourself in the middle of. There are just not a lot of good choices there. So, it goes back to what Roy said a minute ago about you've got to understand what you're buying and dig into the charts and the clinical notes and the financial records. One service we do, and it's something we're doing more of, is called QOE, Quality of Earnings and it's where we look at a whole bunch of questions like co-pays, like whether the revenue according to the practice management software lines up with the revenue that's going into the bank.

[1:22:52] So, that's something we do. We have more questions, unfortunately, than we have time tonight. Once again, a testament to the quality of Roy's material and the great questions that he asked. So, if we haven't gotten your question yet, the bad news is we're not going to. However, Roy's contact information was there on a slide and it will be on the follow-up material that is going out. So, if you want to take it up personally with Roy, I know he loves a good conversation with a dentist. I do. We'll just give you a, because we have a lot of

[1:23:34] new people tonight who haven't been regular webinar attendees. We just want to give you about one minute on Prosperident and then we'll wrap it up for the night. Prosperident really does a few things. Amber, can you tell us about this one? Yeah, this is one that's near and dear to my heart and this is what we call our Office Protection System where we do an examination and review and we look at the integrity of your financial and your clinical side of your office. We look for a lot of different key points that

[1:24:04] help us uncover vulnerabilities that you may have that you may not even know about. So, we look at this as more of a prevent things from happening before it turns into a big problem. So, that's one of the areas that I love to specialize in is looking at both the financial and the clinical integrity of your practice. All right, but that's not all we do, is it, Wendy? Oh, no, that's not all we do. But wait, there's more.

[1:24:33] We are the world's largest firm that specifically investigates financial crimes committed against dental professionals. We do a stealthy investigation so no one in your practice knows that the investigation is occurring except for the practice owner and the people that they choose to bring in other professionals like an attorney or their CPA. So, if you suspect embezzlement has or is occurring within your practice, please give us a call because investigation is not a do-it-yourself type of thing.

[1:25:10] But we're glad to help you with that. And the other thing that we do is that we work with attorneys when basically dentists are suing each other. So, you buy that practice and you find out that co-pays weren't being collected and you've overpaid by $300,000 or $400,000 and you go to your lawyer, they're going to come to us and say, okay, put together an expert report for us and we do that too. Roy and Samir from Care Credit who sponsored this, thank you both very much for

[1:25:42] tonight. That was wonderful. Those of you who are regulars in the audience know that we used to do this monthly and we wrapped that up last September but we had the chance to bring Roy on and we decided to all come out of retirement and dust off our green screens and all our lighting and stuff to do it. I'm really glad that we did. The plan is about quarterly we're going to do this. We'll be making an announcement soon about the next one but I'd like to thank our audience and some fabulous participation from you all tonight. I'd like to thank Samir Basin from Care Credit

[1:26:20] and of course my colleagues Wendy, Amber and Sheila and of course our special guest and treasure friend Roy Shelber. My pleasure. Thank you all very much everybody have a great night. Bye.

[1:26:38] Thanks for listening to the Dental Practice Owners Podcast brought to you by Prosperident. You can contact Prosperident through its website www.prosperident.com or by calling 888-398-2327. If you have questions about this podcast if you would like to discuss your practice or there is a topic you would like to see in a future podcast we would love to hear from you. Amber, Wendy and David will be back soon with another episode.