1. Fraud and Abuse in Dentistry

2. Definition Fraud is the intentional perversion of truth in order to induce another to part with something of value, or surrender a legal right. Stated another way, fraud is “making false statements or representations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist.” Note: Intent based, and acting knowingly and willfully.

3. Types of Fraud in Dentistry Billing for services or products not provided Billing for unnecessary services Billing for services provided by unqualified or unlicensed clinical personnel Knowingly billing for inadequate or substandard care. Filing false claim reports Misrepresenting the nature of services rendered Advertising/issuing coupons/discounts that are not ‘real’ Waiver of insurance co-payments Soliciting/receiving or offering/paying remuneration to induce referrals

4. Definition Abuse is “any practice that, either directly or indirectly, results in unnecessary costs.” Abuse is acting with knowledge, or in deliberate ignorance, or reckless disregard, of the truth or falsity of information.

5. Types of Abuse In Dentistry Failure of follow clinical guidelines or standards of care. Providing unnecessary or substandard care. Violation of participation agreements Making false statements or representations Providing insufficient documentation to support claim for reimbursement.

6. Moral Relevance When acting fraudulently or abusively, the dentist would be violating the following ‘rules’ of morality: “do not deceive” “do not cheat” “do not disobey the law “do not fail to do your duty”

7. What is NOT Fraud and Abuse Mistakes Innocent Errors Good faith interpretations Good faith reliance on professional advice.

8. Consequences of Being Found Liable for Fraud and Abuse in Dentistry 1. Criminal penalties and fines. Fines of up to $250,000 5 years in federal prison/violation Life sentence for patient death 2. Civil fines Fines of $5,000-10,000/occurrence 3x the amount claimed in damages 3. Administrative fines and penalties $10,000-50,000/occurrence Mandatory and permissive exclusion from practice.

9. Collateral Consequences Licensure issues Community trust Financial loss Mobility Office morale and spirit Personal reputation

10. Cost of Fraud and Abuse Some sources estimate the dollar cost of fraud and abuse to be 10% of our health care budget. This would mean approximately $200 billion of our current $2.0 trillion health care budget. Dentistry’s share would be approximately $6 billion of our $60 billion component of health care spending.

11. Shift in Enforcement Environment 1. Department of Justice’s #2 priority. 2. “Health Insurance Portability and Accountability Act of 1996” (HIPAA): provided massive increase in funding for enforcement mandated cooperation among agencies expanded scope of fraud/abuse statues to cover all government payers expanded jurisdiction to reach fraud/abuse against private payers.

12. Federal Resources To Fight Fraud and Abuse in Health Care FY 98 funding = $175.6 million HIPPA requires a high level of cooperation among federal fraud fighting agencies. Today, 551 US attorneys and FBI agents are dedicated to investigating and combating health care fraud; this compares to 346 in 1996 and 112 in 1992. FBI handled 2,700 cases in 1998, compared to 591 in 1992.

13. Results of Increased Enforcement Since 1992, criminal fraud convictions have increased by more than 400%. In 1997, the government recovered $1.2 billion in criminal fines, civil settlements, and administrative penalties. $968 million was returned to the Medicare trust fund. In 1997, 530 suits were filed under the False Claims act alone, generating $625 million in returned funds to the US Treasury.

14. Increased Enforcement (continued) At the end of 1998 there were 3,471 civil matters pending of which 161 had been filed during the year, an increase in one year of 200%. In 1998, 3,021 individuals and entities were excluded from participation in federal health care programs--an increase of 11% from 1997 and 93% from 1996. In 1998, $480 million was recovered in civil settlements, judgments, and administrative actions.