No Background Checks? Dentists Could Be Check-mated!

Previously we discussed the implications of providing care under ANY government-subsized Dental program (especially, but not exclusively as a part of the ACA), and how the onus now falls on YOU, the provider, to ensure your on-going eligibility for those funds. In outlining the increasingly stringent oversight attached to this money, you could find yourself in a "no way out" checkmate situation if you take these checks without performing the proper personal background checks.

Why bother? I’ll make this short and sweet! Submit a claim while you have an excluded person on your staff and you are liable for violating federal regulations. The claim would be tainted by the presence of the excluded person on your team whether or not he or she has any actual involvement with the patient, the claim or the submission of the claim. Your liability can be up to three times the amount of the claims AND fines up to $11,000 per claim. Each product or service is a separate claim. Consider a new patient comprehensive evaluation (remember you do not provide exams anymore), a full mouth series, a prophy and fluoride would be 4 claims.


Potential liability for a false claims submitted for one new patient is three times the amount of your reimbursement (we’ll say $300 to be conservative) plus $44,000. Let’s say (hypothetically) you do monthly exclusion checks. One day, following your most recent check a staff member unbeknownst to you suddenly appears on an exclusion list. Throughout the month you see just 10 new Medicaid patients. Your reimbursement for each patient for the comprehensive evaluation, FMX, prophy and fluoride amounts to $100 each (nice round number to work with).

The next month you conduct exclusion checks and find that the staff member is excluded. You can either keep your mouth shut and hope it goes unnoticed as you tell your staff member to clear their name or, being a person of integrity, you have the staff member clear their name as you place them on administrative (unpaid) leave. In the meantime, you contact your state Medicaid program and self-disclose the mistake to the State as those agencies generally give more leniency to those who use the self-disclosure protocol, as opposed to just getting caught red-handed. The state will likely take back the reimbursement dollar-for-dollar to the tune of about $1000 and call it good.

However, be forewarned, the government has made it very clear they reserve the right to throw the book at a provider who uses the self-disclosure protocol to avoid prosecution. Depending on the scope and magnitude of the self-disclosure, it may be advisable to do so while represented by legal counsel (you have everything to lose, so you better take this seriously).

Let’s say you decide not to self-disclose (whether you separate the employee or not) your liability starts 60 days from the time you discover the issue. After the 60th day you fail to disclose the issue is the point where you will likely face triple repayment and Civil Monetary Penalties (CMP) up to $11,000/claim. CMPs for the 40 claims in this example amount to $440,000. How would you like to write that check to Uncle Sam?

Before you scoff and dismiss this example, this is a very real scenario. Sadly, this scenario is seldom (if ever) this small (dollar-wise) and usually because providers (Dentists, physicians, and even hospitals) do not conduct exclusion checks. The math is always the same formula. You can see how the dollars add up to millions very quickly. Now you have to ask yourself, do you really want to surrender your nest egg to the government over what amount to mistakes or lack of due diligence?

If you accept government money there are strings ropes attached to that money. Those ropes are rules, regulations, accountability and liability. Before you cash the government’s check, make sure:

  • It is righteously obtained (no documentation or billing errors, and not subject to an exclusion of an employee or contactor)
  • It is for the right patient, right treatment, right date of service
  • It reflects the right billing provider and the right treating provider
  • And, it is for the correct amount and supported by proper (thorough, complete and accurate) documentation. (I will expound more on this in an upcoming article.)

There are but a few companies that provide exclusion check services. In the interest of full-disclosure Dental Compliance Specialists, my company, also provides this service. I will not tell you it is cheap. However, it is necessary if you accept ANY government money in your practice.

Avoid being penny wise and pound-foolish. Find a competent organization to provide your exclusion checks and make it happen now! The first check is almost always the hardest and it sucks when your favorite staff person is excluded and you have to let them go, but your glutteous maximus is on the line here. Cover Your Assets!