Increasingly, doctors and hygienists working in larger group practices are required to check off an attestation for the services they deliver. Ideally, attestation is a mechanism to confirm and document that specific designated care was actually rendered to patients.
Company compliance officers may often establish an “attestation check-off” after patient progress notes, within the framework of the computer software. After notes are entered into the patient’s computer record, a click of the mouse verifies services delivered for the appointment. Then, proper billing may ensue.
This action is common in larger dental service organization (DSO) practices as well as in numbers of larger federally qualified health centers (FQHCs), or nonprofit public health clinics. Attestation is highly prominent in dental Medicaid-focused practices, which may potentially be subject to lengthy government audits. Dental Medicaid’s troubling policy of “pay and chase” means audits may go into the past for numbers of years, and into more than hundreds if not thousands of patients’ records.1
A common attestation immediately after the computer patient record entry reads: “I attest that I have reviewed the accuracy and integrity of my clinical notes and claims form and/or services rendered for the date of service indicated above.” The clinician may opt to check a box for “OK” or “Cancel” with a simple mouse click. Yet the implications for a doctor making that click could extend many years into the future (see the figure).
The attestation protocol seems like a favorable device in assisting billing checks-and-balances. All appropriate dental services rendered should be accounted for, which allows for legitimate billing. Unfortunately, like most good ideas, this may also be abused.
Attestation is a common mechanism to place a protection barrier between senior management and actual dental providers when a structured policy of fraud is in place. For example, to make company bonuses and income with a strict payment on production basis, clinicians are too often expected to attest to dental services never provided.
Sealants may be upcoded to posterior one- and two-surface direct resin restorations (CDT code 2391 and 2392, for valid 1351).2 Lingual pits on upper anterior incisors may be restored with sealants, but upcoded to one-surface anterior direct resin restorations, with no preparation into dentin. Other times, no dental care whatsoever is delivered, but the attestation box is checked “OK.”
Clinic directors and senior management are afforded “plausible deniability.” Officers of the DSO or FQHC can claim no knowledge of wrongdoing and “cooperate to the fullest extent possible with law enforcement.” In reality, these individuals are not only complicit in felony and fraud, but are the masterminds. In the meantime, several dentists and/or dental hygienists are thrown under the bus, only to be replaced by the company in rapid order.3,4
Most corporate management will monitor doctor production metrics on a daily basis and thoroughly understand the clinical methodology generating production that is in play. Managers may go to the extent of offering investigators feigned outrage over the actions of their dentists.
Doctors are professionally trained to fully understand that patient records are tantamount to legal records. Patient records cannot lawfully be falsified or altered to generate misrepresentations. Consequences for such actions may be severe. Unfortunately, many doctors today are vulnerable.
Recent grads may be desperate for income. Student loan debt is astronomical and may not be discharged in bankruptcy. Many graduates today are foreign nationals and are potentially at-risk to demands of abusive employers to maintain their resident status.5 Some doctors are simply overly naïve and refuse to believe the realities of fraud in healthcare. Others witness the financial success of those who cheat and also want in on the action.
Regardless of the treating doctors’ situation, they are in the potential crosshairs of an audit and usually face the most imminent negative consequences. Dishonest DSOs and FQHCs may face a fine or penalty, but nothing generally happens to their directors and officers.
A seemingly innocuous mouse click on an attestation could result in potentially many years of future headaches and regrets. DSOs and FQHCs providing Medicaid services are generally too big to fail, while doctors are small enough to jail.
This report is dedicated to the courageous dental professionals who risk their professional standing and careers by acting as whistleblowers in the public interest. These heroes serve in the highest traditions of our profession by assisting taxpayers and protecting vulnerable patients. Thank you all.
1. Centers for Medicare and Medicaid Services. The Health Care Fraud and Abuse Control Program protects consumers and taxpayers by combating health care fraud [press release]. January 18, 2017. https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2017-Fact-Sheet-items/2017-01-18-2.html. Accessed February 13, 2018.
2. US Department of Justice (Northern District of Texas). Texas dental management firm, 19 affiliated dental practices, and their owners and marketing chief agree to pay $8.45 million to resolve allegations of false Medicaid claims for pediatric dental services [press release]. January 9, 2017. https://www.justice.gov/usao-ndtx/pr/texas-dental-management-firm-19-affiliated-dental-practices-and-their-owners-and. Accessed February 13, 2018.
3. US Department of Justice (Western District of Oklahoma). Oklahoma dental clinics pay over $5 million to settle allegations of false Medicaid claims for dental restoration procedure [press release]. October 30, 2014. https://www.justice.gov/usao-wdok/pr/oklahoma-dental-clinics-pay-over-5-million-settle-allegations-false-medicaid-claims. Accessed February 13, 2018.
4. US Department of Justice (Northern District of Texas). Abilene, Texas, dentist pleads guilty in Medicaid fraud scheme [press release]. August 27, 2013. https://www.justice.gov/usao-ndtx/pr/abilene-texas-dentist-pleads-guilty-medicaid-fraud-scheme. Accessed February 13, 2018.
5. Davis MW. Challenges faced by foreign national dentists. Dent Today. 2016;35:10. http://www.dentistrytoday.com/articles/10204. Accessed February 13, 2018.
Dr. Davis practices general dentistry in Santa Fe, NM. He assists as an expert witness in dental fraud and malpractice legal cases. He currently chairs the Sante Fe District Dental Society Peer-Review Committee and serves as a state dental association member to its house of delegates. He extensively writes and lectures on related matters. He may be reached at email@example.com or smilesofsantefe.com.