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Howard:
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It is a huge honor today to be podcast interview Dr. Roy Shelburne from Jonesville, Virginia, which you claim is out in the middle of nowhere.
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Roy:
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Most definitely in the middle of nowhere. Jonesville is the second largest town in the county. The largest town in the county is 1,800 folks, so not a hugely populated area, very rural, in the middle of nowhere.
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Howard:
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Where are you at right now? In your home?
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Roy:
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I am. I'm sitting in my living room.
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Howard:
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That is a beautiful home. Let me read your bio. Dr. Shelburne graduated from the Univeristy of Virginia with a double major in biology and religious studies in 1977. We went on to great with honors from Virginia Commonwealth Univeristy Dental School and opened a private general practice in Pennington Gap, Virginia in 1981. He and his family have served as short-term volunteer missionaries with the Baptist Medical Dental Missions International, and on various missions, the Mercy Projects in Virginia.
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In March 2008, he surrounded his dental license after being convicted of health care fraud and spent 19 months in federal prison, and two months in a halfway house. Dr. Shelburne is a nationally known speaker, writer, and consultant who openly shares his mistakes, what he learned as a result, and how to avoid those career-ending errors. It is a wise man who learns from his mistakes, but a wiser man still that learns from another's. I think you are an amazing man with an amazing story.
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You've given this lecture 100 times or more in the United States. I've seen it. We both were speaking this weekend, this last weekend at the Western Dental Conference, and I had about five of my homies that went to that. They just thought it was an amazing story. We're calling this podcast, "Do Dentistry, Not Time." I'm sure what everybody is wondering is what happened? What was health care fraud? What was it like going from a rich dentist in a mansion like you're at to living in prison for 19 months?
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Did you get beat up? What was that like? Tell your story.
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Roy:
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No, I didn't get beat up as far as that goes. Prison, I never felt threatened. I didn't feel in any danger at all. It was like being sent to summer camp by your parents, and you didn't want to be there. It was more of a punishment to my family, to be honest with you, than it was to me. They suffered a lot more of the consequences. I was out of the world, and they were still in it. I practiced in a small area in southwest Virginia for about 27 years.
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I had flown to San Francisco, California to the American Dental Association meeting there in 2003, and had sat through most of Giuliani's keynote session at that meeting. I was so into what Giuliani was saying when the phone began to vibrate. I didn't notice it. The guy sitting next to me elbowed me, he said, "I think your phone is vibrating." I pulled the phone out of my pocket. It identified that it was my wife who was calling. She knew I was in this meeting and typically would not have interrupted, so I was surprised.
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Rather than interrupting the meeting and heading out to talk on the phone, and walk out in the middle of something, I didn't want to do that so I closed my phone, waited for Giuliani to finish. As everybody poured out of the auditorium after he was done, I called my wife. She had gone to visit my daughter, who was at Virginia Tech at the time, and dialed. She shared this information. She said, "Roy, the FBI is at your office. They've battered down your back door, and they're carrying out all your records."
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I was flabbergasted. Took the breath away. We talked for a couple of minutes, and I tried to reassure her things would be okay, but not in my wildest dreams or in my heart thought that it was nothing. We talked for a while, hung up the telephone, and I called my office. It was on a Friday, didn't expect anybody to be there at all. I was shocked when the male voice on the other end said, "Hello?" I said, "Hello, who is this?" The voice on the other end of the phone went, "Who is this?"
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I said, "I'm Dr. Shelburne. I own the office that you're speaking on the in." I said, "What is this about?" He said, "You are the subject of a health care fraud investigation. I've executed a search warrant. We're gathering information to determine whether or not you're guilty or innocent." I was shocked, as I said. I asked, "What's this about?" He said, "I can't tell you." I asked, "Do I need an attorney?" He said, "I can't tell you that, either."
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I ended up hanging up the phone without any other information other than I was the target of a health care fraud investigation. Sitting in that auditorium in California, I had to figure out what in the world I was going to do. I went back to my hotel. I packed up the bags, and got on a flight. I was back home by about 9:30 that evening, and I drove past my office. It was surrounded by crime scene tape. There were FBI vehicles around the parking lot, around the building, and I watched officers carrying out boxes from my office into these vehicles to haul them away, and didn't go in.
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I called my staff to find out if anybody knew what was going on. They didn't have any idea, so was shocked to find out that in fact I was the target of that health care fraud investigation, and during the course of the next three years, I was under investigation. The FBI took the evidence to the grand jury twice. The first time they weren't granted and indictment. The second time they were. I was indicted on October the 26th of 2006, which taken to ...
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The interesting thing is I was charged with health care fraud, racketeering, and money laundering. Because I was charged with racketeering and money laundering, as I was arrested, there were multiple officers that came with the arresting officer, as well as three flat bed car haulers. Because I was charged with racketeering and money laundering, the government was able to confiscate everything I owned at that point. They pulled the vehicles out of the garage. They put them on flat bed car haulers.
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They had taken control of all my bank accounts, so I had nothing left financially. As I was getting read my rights, I was standing in the kitchen. I had handcuffs on my hands. I had a chain around my waist attached to the handcuffs so I couldn't raise or lower my hands any further than the middle of my chest, and I had leg irons on. The phone began to ring. My wife was standing next to me as this officer was reading my rights. She turned to answer the phone, and he stopped her. He said he couldn't let anything interrupt the proceeding. He was reading me my rights, so my wife turned back around again, and the phone answered.
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This phone answers after four rings, and it was my daughter who was at the Univeristy of Virginia, and through the tears we could hear and understand that she was saying, "Mom, dad, they're here. They're taking my car. I don't need my car. What's going on?" There again, because I was charged with racketeering and money laundering, and the money laundering ... Any amount of money that you have alleged to have gotten that you weren't entitled to and put in a regular business account, as in my office account, any checks I dispersed afterward were subject to seizure.
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That allowed them to take my children's vehicles, as well. Was found. The next day I was transported to the federal prison, or the federal courthouse, was arraigned. I walked into the courtroom. I had never been in a courtroom before in my life. The prosecutor was at the table on the right as I entered, and my attorney and paralegal was on the left. I sat down. My attorney asked how I was doing, and I of course responded, "How do you think I'm doing?" The second thing he said, "Well, I've got good news and I've got bad news."
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I said, "What's the good news?" He said, "The good news is that we've arranged bail. You will be going home tomorrow." I said, "That's good news. What's the bad news?" He said, "The bad news is as part of the bail agreement, the prosecutor has required that you surrender your license to practice dentistry." In a moment my life vaporized. Everything I had built and worked for those 27 years prior to basically went up in smoke. There were several providential things that happened in my life, and this was one of those days, one of those times.
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General what the judge would have done, he would ask for the allegations, and the prosecutor read those. As far as the allegations, it was health care fraud, racketeering, and money laundering. As soon as the prosecutor said racketeering and money laundering, the judge stopped him, he said, "You understand, sir, that those statues were never intended to apply in a situation like this?" I thought that sounded pretty good, but the judge took another deep breath and said, "But in instances like this, courts have ruled that it is applicable, so I will allow it."
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Then got to the point of bail and going home. Typically what would have happened, the judge would have asked the prosecutor if there would have been agreement, he would have said yes. The judge asked for the terms, and he did in this case. The prosecutor had began to explain as far as the charges, and then got to the part about the bail. The prosecutor states, he said, "I request that Dr. Shelburne's license to practice dentistry be suspended." Typically what the judge would have done would just look at my attorney and ask if there were any objects.
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He would have said no, and my license would have been gone, but the judge in this instance didn't do that. He looked at the prosecutor and asked, "Does the Board of Dentistry of Virginia still exist?" The prosecutor says, "Yes." Then the judge asked, "Are they aware of the situation?" The prosecutor said, "Yes, they have," because they had alerted the board, and I had been in contact, as well, because during the investigation I wanted to make sure I wasn't doing anything I was supposed to. The judge, rather than asking my attorney if there was any objections, he went back to the prosecutor and he said, "So, sir, you're asking me to supersede the power that the governor has given to the Board of Dentistry to determine if individuals can practice dentistry appropriate and in the state of Virginia."
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"You're asking me to supersede that agency. Is that what you're asking?" I'll never forget the look at the prosecutor's face when he looked at the judge and he said, "I guess." The judge said, "No. Until the board acts on this man's license, he can practice dentistry." Something providential happened, and then I was still able to practice dentistry. Interestingly enough, Howard, the best year I ever had financially in my dental practice was the year after I was indicted, and the year before my prosecution.
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You know how you'll diagnose work for patients, and they'll postpone it for some reason? That happened through my career, as well, but for this period of a year and a half, patients would come in and, for example, I diagnosed a ridge. They would say, "Dr. Shelburne, you know we've talked about that bridge, and I know I need it. I want you to do it, but I don't know if you're going to be here or not, so could you go ahead and do it now?" It was interesting.
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The message to take home from that is a lot of times, we assume patients will make judgments based on some external thing going on. Was there certainly enough doubt placed in patients' minds that they would, if they thought it was important, just go to somebody else for treatment? They didn't for the most ... Most of them did stay loyal, and like I said, did want me to do their dental work. During that year, that was the busiest year I ever had. Like I said, message to take home.
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Be careful about those relationships you develop with your patients, because that's going to say a lot more than what outside entities can say about you and against you on the inside. There were a lot of things I learned in the process during the investigation and during the prosecution that I think is important for dental practices to know. There are a lot of things that I didn't know. Things that I did, things that I didn't do that I should have done, or not should have done that I didn't understand how important they were.
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One of the things that became very evident is the fact that your clinical record is a legal document that can establish medical necessity and can testify for you very directly if you choose to focus on that document in a way that does build that foundation about what you did, establishes medical necessity, and it also outlines your thought process in a way that will testify for you. You don't even have to open your mouth. One of the other things that was very surprising to me was the legal definition of intent to defraud.
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I thought if you defrauded somebody, intent meant that you submitted a claim for a patient you never saw for a service that you never did, and certainly that would be intentionally defrauding. One of the things I didn't understand is what is included from the legal standpoint to find this blind disregard. That's in instances where you continue to do something the same way in error, and not having systems in place to identify and correct those errors. That's considered blind disregard and intent to defraud.
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Literally, ignorance is no excuse. The billing in my office was done by a business staff person, as it is in most office, and I thought if there were mistakes made, that I could return any error, any money that I got in error, and there wouldn't be ... Or any penalties, or anything else that they deemed appropriate to reimburse. I was never given that option. The only option I was ever given to settle prior to going to trial was three years in prison and a restitution in $300,000.
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Another thing that was shocking to me is that the money really didn't make any difference at all. The county that I live in is beautiful. It's an amazing part of the country, but unfortunately it is the poorest county in the state of Virginia. If you Google MSN your state and the poorest county in the state, you'll be able to find out what the poorest county is, and in my case, when I Google that, Lee county, which is the county I practice in, is the poorest county in the state.
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As a result, we had a great number of patients who were qualified for Medicaid, who were Medicaid patients. In fact, over 90% of all the individuals in the county at the time under 18 were qualified for Medicaid, and we saw a number of Medicaid patients had a very busy Medicaid practice, as well as fee for service, as well. About 50% of our payment for the practice was from Medicaid services. When the government did the evaluation, they looked at six years of submissions, and during the six years, I was paid $3.5 million from Medicaid for the services that I provided.
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Is that a significant number? It absolutely is. At the time I was number five in the state in terms of the doctor who had the highest reimbursement, and I was paid about $3.5 million during that six year period for the reimbursement of services I provided for my Medicaid patients. The amount that I got that I wasn't entitle to that the government established of that $3.5 million was $17,899.57. That's about 0.5% of the amount of payment I got. I thought that was a pretty good error percentage, but really the money makes no difference whatsoever.
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The interesting thing is it had to be a jury trial, and the jury is never made aware of the amount. They had no idea it was $17,000. They could have assumed it was $300, $400, $1 million as far as that goes, so they never determined the amount. That's determined by the prosecution during sentencing. It's interesting that it had to be a jury trial. I don't know if you're familiar with how the jury selection process goes, but in my case, the jury pool was about 50 people.
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The judge starts by interviewing the jury and determine if there is any association that they have, have been a patient, or if they knew the prosecutor, or if they knew my defense attorney. They eliminated 15 of those to start out with, which left a group of 35. Of the 35, there was one hygienist and one chair-side assistant left in the pool, and the way that you go from 35 down to the 12 jurors, it's like a reverse pickup basketball game. The prosecution eliminate one. We eliminated one. They eliminated another. We eliminated another until we got to 12.
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How would you like to guess the two individuals that the prosecutors eliminated first on the jury?
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Howard:
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The hygienist and the assistant.
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Roy:
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You best believe. They want nobody on the jury that knows anything about what we do. Those are our patients that make a determination. In my case, there was one account of health care fraud, and there were 119 instances brought that could have been construed as health care fraud. They had 119 chances to prove my guilt of health care fraud. The allegations, they were pretty widespread. It was provided unnecessary treatment, I provided worthless treatment, I billed for things that I didn't do or billed inappropriately for things that I did do.
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There were 119 chances that they had to prove one case of health care fraud. Taking in consideration that those were our patients on the jury, there were expert witnesses that testified on both sides. The prosecution had expert witnesses that testified on their point of view, and we had expert witnesses to testify from our point of view. The interesting thing is the widespread beliefs and positions of dentist as expert witnesses. Howard, if I gave the same records for the same patient to five different dentists to put together a treatment plan, how many different treatment plans would we get from those five different dentists?
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Howard:
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Five. That was established in the Reader's Digest article back in the day.
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Roy:
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Or seven or eight. There were a couple of practitioners who couldn't figure out one, so they generate two or three. Our patients don't understand that. In fact, if you look at Yelp! Reviews, the number one reason for bad Yelp! Reviews to dentists is a lack of conformity in treatment plans. They complain that they got one treatment plan from one dentist, and they went to another dentist, and a lot of the things that the first dentist may have suggested weren't listed in the treatment plan in the second.
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There's inconsistency there. Our patients, what would they believe? If they went to five different dentists, how many different treatment plans would they receive? None. They would all be the same. They don't understand that there's a difference, and that's one of the difficulties. Have a friend who began her career as a dentist, and then went to law school. She now provides legal support for dentists and doctors in malpractice actions. These are her words.
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She says that if you try to have one doctor testify against another doctor, that almost never happens unless it's so awful that anybody would look at it and say that was a bad result. She said as far as dentists go, you ask for one dentist to testify against another dentist, she said, "Literally, individuals will line up outside the door and around the corner to throw the other dentist under the bus." That's the world we're living in. We have a built-in expert testimony individual who will always testify against somebody else.
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Experts don't always agree, but our patients don't understand that, and jurors don't understand that. Some of the allegations, they revolved around things like overtreatment, where they would have an expert that said for primary teeth that were decayed to any significant extent, that tooth should be extracted. I did a lot of [inaudible 00:21:56] to crowns to build teeth back up again, but what do our patients think? I don't know if you've ever had an opportunity to have a patient, a child who needs a particular filling, or maybe a stainless steel crown or something like that.
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You propose the treatment plan to the parent, and the parent's response is, "That's a baby tooth. Why don't you just pull it?" A lot of times, that's what our patients think. If the argument to the jury was, "He overtreated these patients by putting this very expensive dental work in by crowning these teeth," and then you had an expert witness that indicated that they would have extracted the tooth. By the way, those jurors are probably tax-payers, and they may have children that they're struggling to provide care for, and yet this patient comes in.
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They have Medicaid, their tax money is paying to have a treatment provided for this young person, and this doctor is providing Cadillac treatment, or maybe unnecessary treatment for this patient when they feel that a baby tooth is just something that can be pulled without any instance. You can see where the jury may think, "Yes, he overtreated that patient, or he did something inappropriately." They had an expert witness, a dentist who said that if the tooth was extracted to any great degree, that they would recommend taking the tooth out.
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There was another instance where endodontic procedure had failed, and the prosecution's position was that I had provided a worthless service, that endo had failed that needed to be extracted after three years. Interestingly enough, they had an expert witness, a dentist who testified that they had never had an endodontic procedure fail. My response to that, I groaned a little bit. My attorney during the break, he said, "What was your response? Why did you respond that way when that dentist said that they never had an endodontic procedure fail?"
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I said, "You do to any great extent, the best practitioner is going to have probably a 5% failure rate." He looked at me and goes, "Really?" Even educated people like my attorney don't understand from a dental perspective that what we do is not 100% effective. There was an instance where the prosecution had suggested that the treatment that I provided, a regular simple restorative procedure was unnecessary. They had an expert dentist who testified that, if the carious lesion was not evident on a radiograph, it shouldn't be treated.
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Obviously a very conservative person, but from a patient standpoint, again, do they understand? Not so much. I guess message to take home is that, in this particular instance and with that case, let me give you an example. My attorney in order to be able to help support my case went through all these 119 instances and had me support my decisions, or the treatment that I provided. There was the case where the indication was that I had provided treatment that was unnecessary.
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My attorney asked me, he said, "Dr. Shelburne, what do you typically do to determine treatments necessary?" I went through the whole litany, and I said, "We start by a visual examination. We have an explorer. We can feel the tooth. We have radiographs that will help during the diagnostic process. We have sopro or diagnadent that help to diagnose, as well." I went through the whole litany to support what I typically did to determine treatment was necessary.
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It becomes the prosecution's time to refute everything that you say and do. It got into this particular patient. He asked me, he flashed a copy of my record in front of the jury on a screen. They had a television screen for them to view. He asked me, "Dr. Shelburne, can you identify for the sake of the jury that this is the patient in question?" I looked at it, and I said, "Yes, that's the patient that the allegation is from?" He said, "Can you identify the date that you did the evaluation, and the date you did for treatment?"
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I pointed to them, I said, "This date and this date." He said, "Dr. Shelburne, you did an amazing job describing what you typically do to determine treatments necessary. That was wonderful," and by the way, if a prosecutor ever compliments you, what comes next is not going to be very pretty. His next question was, "Dr. Shelburne, for the sake of the jury, can you please identify where it lists on your clinical record this document that you reported? Where does it indicate that you did any of those things to determine treatment was necessary?"
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I looked at the clinical record and had evaluation and the list of all the services that I had suggested necessary. During the treatment, also, same thing, had just a list of treatment that I provided, and I said, "I didn't record that I did any of those things." He turns very dramatically and faces the jury and he said, "Well, now that I guess we find you in this position, we'll just have to take your word for it that you did those things, won't we?"
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Had I taken more time to be able to record the reason why I determined treatment was necessarily, that record would have testified for me to support the fact that I did go through that process to determine treatment was necessary. In that instance, your treatment record can help to substantiate your treatment decisions. I spent a lot of [inaudible 00:27:29] then looking at clinical records and what's necessary, as well as some of the billing coding issues.
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To bring that to today, and some take home for some of the podcast's listeners, I go to the AADC meeting, the American Association of Dental Consultants, and the NADP meeting, the National Association of Dental Plans. Those are meetings that the dental plans, the insurance companies meet, as well as the doctors who work for the insurance companies that do those evaluations, determine whether they approve air [pre-Ds 00:28:05] or the treatment provided.
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You listen and you are able to understand what those insurance companies are now focusing on, and areas that they feel that dentists may be abusing the billing and the coding and the submissions. To highlight one of those in particular, and why it's important to document as well as support that information, radiographs have become a huge area of concern for insurance companies. Or a radiograph to be taken, it needs to be deemed medically necessary, not because the insurance is going to pay for it.
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If you want a good baseline, a good reference to determine about radiographs and what those recommendations are, the ADA and the FDA in 2006, it's been updated in 2012, put together a document that outlines what's considered appropriate in terms of that diagnostic consideration as well as, they put together a grid that aligns patient risk, age of patient, and a lot of contributing factors what's recommended for those radiographs. In order to justify radiographs as far as medical necessity, number one, there needs to be a reason for them.
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For example, you take a bite wing to perhaps determine if there's been a proximal decay, perhaps bone level, and approximately as well. If there's justification to be able to determine that based on the patient's age and risk factor, the doctor has the assistant or hygienist take those radiographs once that medical necessity is determined. Number two, it's important that they be of diagnostic quality. There's an instance where a dentist in your neck of the woods, actually, in the southwest had sent a pre-estimation to the insurance company for a crown, supported by a PA radiograph.
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That PA radiograph that was sent in to help justify that need was not a very good PA. As far as the quality, it was not good at all, and the person who was doing that evaluation looked at that radiograph and said, "Wow. If this practitioner thinks this is a diagnostic film, I wonder what we'll find if we do an evaluation audit of this dentist." That triggered an audit. What they did is they pulled 20 charts, and from those 20 charts they determined that 10% of all the radiographs that were taken in those 20 charts were non-diagnostic.
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What the insurance company did, they used that 10% amount, and they looked at all the payments for radiographs made to this dentist over the course of six years, and they asked for 10% of the amount of money that they paid for all the radiographs for this dentist over that course of six year, and that dentist ended up writing a check back to the insurance company for $72,000 to reimburse them for non-diagnostic films.
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I encourage you to look at your radiographs to make sure that, number one, when you're submitting them that they're medically necessary, number two, that they are diagnostic quality, and number three, the notation needs to be made that the dentist has read them. Interesting, with the new CBCT codes, there are now codes number one for capture only. There are codes for capture and interpretation, and then there's a third code set for just interpretation.
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It's becoming more in the medical area, in terms of qualification for reimbursement for radiographs, number one, they need to be necessary that they are diagnostic, and number three, that they are read by an individual. Components of those need to be in that clinical record. To dive a little bit deeper into the radiograph area, for example, patient comes in complains of pain on the upper right hand side. They point to number two. The doctor talks. The assistant says, "I'd like you to take a PA," and the first PA is taken.
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It's decent, but it's not the best film in the world. Ask the assistant to take a second one. The second one is taken, not as good as the first one, and doctor orders a third one, and the third one's taken, and it's perfect. Gives all the information that's necessary. In terms of billing for those services, you only bill for one, even though you've exposed three, but you need to make a notation in your chart to track exposure to the radiographs that three were taken.
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There are again in offices you have to be very careful when you make those notations that you do it in a way that the person who's going to build that out could see that three were taken, but only one should be billed for. Then I'm going to slice and dice it a little bit more here in terms of billables for radiographs. For example, if a patient comes in and they're missing number one and number two, and number 31 and number 32, and the doctor maybe not as focused as he or she needs to be and says, "Go ahead and take the bite wings."
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The assistant assumes there's four bite wings necessary. On the left hand side, the first bite wing gets distal canine, the middle of molar, and the second one gets middle of pretty molar back to the edentialist area, and on the right hand side, the radiograph's taken that has distal canine to the middle of the molar, and the second one is taken middle of the pre-molars back into the edentialist area. Four are taken, and a lot of times when I ask my attendees to my lectures, I ask how many do you bill for?
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Four is taken, and they say four. In this case, on the right hand side where you're missing the second and third molars, there's no reason, no medical necessity to take the second pre-molar, or the second film on this side, so technically as far as medical necessity, you would only take three. The fourth film on the right hand side would be considered medically unnecessary, and if billed, there could be an issue regarding whether or not that should be reimbursed as three or four.
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Be careful when you order those radiographs that they do provide diagnostic support on label for whatever that radiograph is taking. There's also if you see patients, for example, children who have diastemas between all their teeth. That happens in some cases when the jar arch is much larger than the tooth size. Would there be a medical necessity to take bite wings on a patient like that? The answer is probably no, because all the inner proximals are open.
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You can get your eyes in between, and you can get an explorer in between. If you've taken bite wings on a child with diastemas between all their teeth, could that be considered medically unnecessary and unpayable by the insurance company? It absolutely could, and so [inaudible 00:35:01] films as far as that goes, too. A child that has diastemas between all their teeth in the anterior region, if you take a [inaudible 00:35:10] film, you're not getting any information that's going to be beneficial unless you're looking at something other than the carries area.
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If the child is a little bit further in the progress as far as development goes, then you might be ordering those bite wings to see eruption or the areas of the roots of the teeth to find out when it might be exfoliated. That's a different issue. It would be justified that way, but you have to be very careful in determining the need that it does relate to medical necessity, and that radiograph is necessary. That takes it from medical necessity, and what I've learned in my process, and to today's practice to make sure that you're billing and coding things appropriately to make sure that they are justified from a medical standpoint.
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There are all kinds of different variables in our practice now in terms of what we can use and some of the things that we can bill for. You have to be aware of the fact that medical necessity is something that needs to be established in that clinical record, and that it is accepted as medical necessity. Another area of focus that insurance companies have are making sure that, for example, if you close diastemas, if it does fill the inner proximal and does go to the incise ledge, say between 8 and 9, a patient presents with a diastema between 8 and 9.
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You close that diastema. The code that would best describe that would be probably a D2335, the code that describes a composite resin four-surface or involving the incisal angle. The interesting thing, and the problematic thing, is in cases like that, the diastema closure is a cosmetic thing, and it's not a medical necessity. If you're closing it from a cosmetic point of view, the code that you would describe would be 2335, but if you aren't very diligent about making a notation in that clinical record that it was a cosmetic closure, could that person who you do your billing look at that and see that you did an incisal angle composite, and submit that to the insurance, and get it paid for?
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All is good until it's determined, perhaps by a audit from the insurance company, that that was actually a cosmetic type closure. You got paid for something that is not medically necessary. Could that be considered a fraudulent act? It could be. You have to be careful, especially with something in that nature, if the tooth is fracture, and medical necessity would indicate that if it's fractured in the denton, restoration would probably be justified.
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If there's a faulty existing restoration that's leaking, that's being replaced, would that be medically necessary? Yes. Make sure that that billing is tied to medical necessity and it's not a cosmetic issue. Otherwise you could be held accountable for billing for a non-covered service and making it mask as a covered service. As far as disclosing to the insurance company discounts, that's also something that's very important to make sure that the billing that you're sending to the insurance company, the amount on that claim form does reflect the amount that you expect to accept as payment in full.
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For example, if you offer cast discounts to patients, the amount that you have agreed to the patient to accept for that service is less than your full fee, then you need to put on that claim form your fee. For example, if you have a 5% courtesy, and I'm just going to throw the number out there as far as a crown. If your crown fee is $1,000, 5% courtesy, you're actually going to accept $950 as payment in full for the service that you provided. On that claim form, the amount that should be listed is the $950 because that's the accurate number that you're going to accept as payment in full.
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If you submit as $1,000 and do the write off without disclosing to the insurance the proper amount, that could be considered insurance fraud, as well. There are all kinds of instances where you need to be aware of what is considered fraudulent. For example, I would imagine 99.9% of the people who are listening to this podcast have had patients ask them to commit insurance fraud. That would relate to the date of the claim. For example, a patient comes in, and they've maxed out their benefits for a particular year.
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Howard, I'm going to chase a rabbit here. I have ADD, so this is one of the instances where I'm going to chase that rabbit. The reason why I know I have ADD, that's the only test I've ever taken in my life and scored 100% on. A lot of people, the insurance maximum that has been established over the past ever, $1,000, $1,500, $2,000. Do you have any idea why that number has not changed? Why it's still the same amount?
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Howard:
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Why is that?
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Roy:
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The insurance companies, they use a lot of data to be able to determine their fees and patients' utilizations, and one of the things that was most shocking to me was this statistic. Of the patients in the United States that are covered with dental insurance, how many of those patients, what percentage of those patients actually use the maximum per calendar year? What percentage would you think that is?
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Howard:
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20%.
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Roy:
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It's 11. 11% of the patients with insurance actually maximize their benefit per year. The insurance companies point at that and go, "Why in the world would we raise our annual maximum when only 11% of our patients covered use their benefits to the maximum?" Just FYI, you need to ... That's the reason why that number is not changing, why it's never so small.
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Howard:
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If you go on the Dentaltown app, and there's a little search bar there which I hope you guys like, because it cost me $50,000, because we have a 210,000 dentists have posted 4 millions times, that $50,000 Google box will rip through that in a second. I typed in Roy Shelburne, and there's a thread with your name on it. I posted a picture of us. I am podcasting Roy right now. Does anyone have any questions for him?
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First guy said, "Tell him Dr. Massey from Pell City, Alabama said hello. People can make their own decisions about what Roy did or did not do, but if you want a third party to audit your charts, I highly recommend Roy." Open Contact said, "If you could ask Roy why he was targeted? Random, employees, revenge?" Roy, just to be clear, you're basically saying that you were a Medicaid provider. For international people, Medicare is a federal insurance program from Washington, DC that covers the elderly, over 65.
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Then each one of the 50 states has a Medicaid as opposed to Medicare, and it's generally for the poor. You were saying you were in Virginia. You were a Medicaid provider. You did about how many million dollars did you do? Three million bucks?
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Roy:
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Three and a half million. Yeah, about 50% of my practice was Medicaid. Half.
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Howard:
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Half was with the state, and then onto your audit, you were basically about half of a percent.
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Roy:
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Yes, true.
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Howard:
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To be clear to viewers, you weren't intentionally billing for crowns you didn't do. These were errors by your dental office, staff?
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Roy:
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Yeah. The blind disregard means that you made errors, and we did, but we get paid money that we weren't entitled to. The interesting thing is, we were able to establish that there were services that we provided should have billed for and could have been paid for that were in excess of the $17,000, but we didn't, but that didn't make any difference.
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Howard:
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Are you basically, it sounds like this was a total abuse of federal power, or state power, or federal power, FBI.
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Roy:
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They didn't abuse anything. No, anything that they did, they were entitled to do. In most cases, if Medicaid takes an action, it's because a dentist has been non-compliant for a number of years. Medicaid actually did two audits during, after the investigation. The first audit came back clean. The government actually instructed them to do a more comprehensive audit on the second set, and they actually pulled the patient records that I did the most ... The 15 patients that I did the most comprehensive work on.
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When Doral Dental, which is now Dentaquest, they did an internal audit because they were-
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