(April 25, 2012): Yesterday we discussed issues surrounding returning an identified dental overpayment to Medicaid or other payors. Below is a continuation of this discussion. Dentists, oral surgeons and their staffs may ask “What types of actions might constitute an “identified” dental overpayment?” That’s a fair question, especially since the Affordable Care Act does not provide much direction in this regard. Nevertheless, there are a number of situations that could signify that an overpayment is present. Examples include:
- A routine dental office audit discloses full payment by a beneficiary’s primary and secondary payor for the same claim.
- A dental practice learns that one of their employees or providers has been excluded from participation in Medicare or Medicaid.
- An anonymous employee of the dental practice alleges that orthodontic claims are being improperly billed to Medicaid.
- A parent of a dental patient calls and states that her child never received a certain service that was paid by Medicaid and is listed on the “Explanation of Benefits” form sent by the payor to the patient.
VIII. What Must a Dentist do if a Medicaid Dental Overpayment is Identified?
Pursuant to Sec. 6402 of the Affordable Care Act, all providers (including dentist) are required to:
- Report and return the overpayment to the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at the correct address; and
- Notify the Secretary, State, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment.
In summary, once a Medicaid dental overpayment has been identified, a dentist must report and refund that dental overpayment to the government, within 60 days of the date on which the dental overpayment was identified.
Additionally, once any Medicaid overpayments have been returned to the government, any associated co-payments paid by beneficiaries must also be returned. See 42 C.F.R. § 489.41.
Importantly, you need to assess the nature of the mistake and determine whether this “error” or other action which resulted in the dental overpayment was an isolated event. If not, under the government’s interpretation of the repayment rules, you likely have an obligation to repay other similar errors from prior periods. Keep in mind – your obligation to repay funds that do not belong to you extends far beyond the provisions of the Affordable Care Act.
IX. Taking Corrective Action
In today’s enforcement environment, it is essential that you know, beyond a shadow of a doubt, whether you are fully complying with applicable coverage, documentation, medical necessity, coding and billing requirements.
As a first step, we recommend that you “Identify your weaknesses – then correct them.” If you have not already done so, engage qualified legal counsel and conduct a “Gap Analysis” of both your dental business operations and your coding / billing practices. In most cases we have found that dental practices have learned of deficient practices of which they were completely unaware. The steps to take include:
- As a first step, dental and orthodontic offices should review each of the regulatory and statutory provisions related to the specific services being billed to Medicaid.
- Next, these offices should compare their actual documentation, coding and billing practices with Medicaid’s rules. Any “Gaps” between the applicable requirements and a dentist’s / orthodontist’s actual practices must immediately be remedied.
- Additionally, should these “Gaps” represent an overpayment, the Medicaid provider must repay the overpayment to the government within 60 days of identification.
- Prior to conducting a “Gap” analysis, you should contact your legal counsel for advice and assistance.
Once remedial actions are taken, the next step is to design and implement an effective Compliance Plan. Despite the fact that significant strides in compliance have been made by large providers (such as hospitals and nursing homes), it has been our observation that most dental practices still do not have a tailored Compliance Plan in place.
To be clear, we recognize that many dental offices may have copied draft Compliance Plans off of the internet or purchased a sample plan from their local association. While they may fully intended to follow through with personalization of the draft document, in most of the cases we have seen, more pressing events have taken precedence and these dentists have not had the time or expertise to complete the project. As a result, we recommend that you engage qualified legal counsel to assist you with this project. The benefits of an effective Compliance Plan can be significant, and could conceivably mean the difference between an aggressive investigation and a mere cursory review by the government once they learn that you have taken multiple steps to better ensure that your operations and practices fully comply with applicable Federal and State requirements.
Liles Parker is a full-service health law firm focusing on regulatory compliance and representing providers in health law and business matters. Our attorneys are highly skilled in designing and implementing effective Compliance Plans for dental practices, orthodontic practices, and other health care providers. Moreover, our attorneys are experienced in handling an array of complex health law matters, including the appeal of alleged overpayments to Medicaid. For more information on how we can assist your practice in developing an effective dental compliance plan, call Robert W. Liles, Esq. Robert is a Managing Partner at the Firm and can be reached at: 1 (800) 475-1906. Call him today for a free consultation.