On August 11, 2015 the Hartford Currant published a news article that should terrify every dentist who participates with Medicaid. Whether you are a Medicaid provider or not sit down and read this!
Dr. Thomas DeRienzo, owner of Plantsville Family Dentistry in Plantsville, Connecticut, “was charged with first-degree larceny by defrauding a public community, second-degree vendor fraud and insurance fraud for the false claims” submitted to the state’s Medicaid program from 2010 to 2014.
Here is the breakdown of the allegations of this five-year period, as reported by the Courant
Claims miscoded: 282
Claims not supported by clinical documentation: 67
Claims found to be not “medically necessary”: 193
Amount of alleged fraud: $7,213.92
It was reported that Dr. DeRienzo faces a maximum of 35 years in prison if convicted.
Here are my thoughts:
- As human beings we are all prone to mistakes. Even with the best audit systems in place mistakes will happen.
- Dr. DeRienzo faces prison time because he and his staff didn’t catch 542 mistakes over five years. That’s about 108 mistakes per year (about 2 mistakes per week) averaging about $1443 per year (about $27.75 per week).
- Dr. DeRienzo faces up to nearly 1.5 months in prison for each error he didn’t catch and correct (or prevent)
- There is no telling how much the State of Connecticut is spending to investigate and subsequently prosecute this case. However, I am certain the amount spent to investigate the case far, far exceeded the amount of “fraud” Dr. DeRienzo is alleged to have committed.
- I have to wonder what Dr. DeRienzo did to exacerbate the situation, as criminal prosecution in this case seems unwarranted and unjust (or “no justice” meaning not equitable or fair). It seems the taxpayers of Connecticut were screwed twice, once by the dentist and again by the state’s attorney. This seems a very poor return on investment when a repayment plan should have been executed. I can only surmise Dr. DeRienzo really pissed someone off. (there’s a lesson there)
- On face value, I find it highly unlikely this alleged fraud was deliberate considering the low volume of affected claims and dollar amount. In my investigative experience, fraud is usually blatant and consistent.
- One thing you need to know. Under the Affordable Care Act, the government is no longer required to prove intent. Intent it assumed. That means intent to defraud is assumed on every mistake you make.
I have audited thousands of dental records for hundreds of dentists. From my experience I tell you it can be very difficult to distinguish between deliberate, purposeful fraud and 20th Century recordkeeping in a 21st Century world. In other words – documentation that is good by yesterday’s standards, but is grossly inadequate by today’s standards.
I frequently find between $27.72 and $1442 worth of undocumented or improperly coded claims in a single 10 record chart audit. This is surprisingly common, but few dentists realize the mistakes they and their staff make because no one checks except for an occasional audit.
Having audit processes in place is crucial to ensure quality standards are met, compliance obligations are fulfilled, errors are prevented and/or corrected to minimize liability exposure. This is not an issue specific to Medicaid. Every practice is wise to implement audit processes. In fact, there are multiple types of audit processes with different focuses. Periodic audits are essential to help identify blind spots you are too close to see, to validate internal audit processes and further minimize your liability exposure, as we are human and mistakes will occur in the best of circumstances.
When I think about billing issues Newton’s Third Law of Motion comes to mind, which states, “For every action there is an equal and opposite reaction.” Since money is constantly in motion into and out of dental practices, this seems fitting. I find nearly as many underpayments as I do overpayment issues. Often the number of underpayments is less frequent, but is for higher dollar amounts. What this might look like is multiple procedures provided in a single case, such as multiple extractions and alveoplasties, but for whatever reason the staff fails to bill out one of the implants and/ or an alveoplasty. Consider the implications of underpayments as much as with overpayments.
While overpayments are recouped dollar for dollar outside of federal healthcare programs, within Medicare/ Medicaid the recoupments involve triple repayments plus fines and penalties up to $11,000 per claim and this is just for a civil case. The powers at be can decide to prosecute criminally like they did in Connecticut- or both.
One question remains and only you can answer it. Knowing the hazards of your billing practices what are you going to do to minimize your exposure? My number is (817) 755-0035. Let’s talk about it.
A former Law Enforcement Officer/ Dental Board investigator Mr. Duane Tinker is the CEO of Dental Compliance Specialists. Mr. Tinker and his compliance specialists provide compliance consulting, auditing and training services for dentists and Dental Service Organizations nationwide on compliance risks including OSHA, HIPAA, Dental Board rules/ regulations, state radiology rules, DEA and state drug regulations, and Medicaid. He often speaks for dental societies and study clubs. Mr. Tinker can be reached at (817) 755-0035 or click here to email.