Dental Audit Lawyer

Facing an audit as a dental health provider can be one of the most stressful experiences that you may ever have to do in your professional life. While an audit does not necessarily mean that anything is wrong, it could lead to criminal charges that threaten the solvency of your practice, jeopardize your license, and even result in a prison sentence.

Working with Medicare and Medicaid is a complex process. While having patients whom you know can pay for your services can provide a steady revenue stream, these government programs require strict documentation and privacy procedures.

Failure to comply with these procedures could put the Centers for Medicare and Medicaid Services (CMS) on notice and an audit could follow.

Audits could happen at a moment’s notice and may be the result of a customer complaint, a red flag triggered during the billing process, or even as the end product of an CMS investigation. Regardless of the source of the audit, it will examine virtually all of your business practices.

It is vital that you work with an attorney who could your best interests during the audit process. This includes working with the auditor during the gathering of information, working to help you make good-faith explanations for any apparent discrepancies, and even helping to defend your freedom and your business in case of any federal criminal charges.

A dental audit lawyer could provide this essential help. They are familiar with the Medicare and Medicaid audit processes. They can work with you to explain why the audit is happening, and make sure you know your rights during the audit.

The Purpose of a Dental Audit

Practicing dentistry requires providing care for patients, but receiving fair compensation for that work requires paying attention to business issues in addition to providing that care. Of course, most patients pay for such services through insurance including insurance provided through the Federal Government. Medicare and Medicaid programs provide dental treatment coverage for millions of senior citizens, people with disabilities, children and those who lack the financial means to obtain any other form of insurance.

As a result, many dentists accept these patients for treatment with the understanding that Medicaid and Medicare will provide reimbursement. These programs have many advantages. Dentists can provide a service with a solid understanding that they will receive payment, while the government knows how much a procedure should cost for every patient.

What Might an Audit be Looking For?

Dentists have an obligation to bill properly for their work. Whether the insurer is a private company or the Federal Government,

it is easy to see why proper record keeping is essential for any dentist’s office. Every patient’s file should indicate the work performed, as well as a copy of the bill for such services. An audit’s purpose is to look for any discrepancies in this paperwork.

One common example of poor record keeping leading to great problems for dental offices is an inadvertent double charge. Something as simple as a clerical error committed by an office assistant could result in the practice submitting a double bill for services to Medicare or Medicaid. Even though the dentist did not intend to defraud the government, the end result does indicate a double payment for a single patient visit.

An audit could also search for inflated charges. For example, a patient may visit an office for a partial denture. The dentist performs the necessary work for the partial denture and sends the patient on their way. However, the medical bills may indicate that the patient received a full set of dentures, even if the treatment indicated it was a partial denture.

Finally, an audit may evaluate the procedures used by a dentist office to keep their patients’ medical records secure. The Health Insurance Portability and Accountability Act “HIPAA” places the burden on all medical providers to keep this information a secret. Systemic failures to do so could result in the removal of a dentist from an approved list of providers for Medicare or Medicaid. A dental audit lawyer could help educate dentists as to the sorts of infractions and mistakes that an auditor may be looking for during an audit.

The Classes and Purposes of Various Dental Audits

Audits that affect dental practices are not one-dimensional. Different types of audits are precipitated by different events each with their own procedures and potential outcomes.

The safest audits are those that the dental practitioner orders themselves. These can serve as an effective tool to stave off future government audits. In short, an office may hire an employee whose job is to double check all Medicare and Medicaid claims, to ensure the integrity of all patient records and bills, and to implement security steps to protect patient privacy and records.

Larger practices may wish to hire an outside firm to serve this function. Especially larger dentist offices who may be handling hundreds of patients a week can quickly become overwhelmed with the vast amounts of required paperwork and the regulatory schemes that control proper Medicare and Medicaid claims. An outside firm can also implement new procedures and train the clerical staff.

Of course, CMS can also instigate their own audits. The most straightforward of these audits are known as Recovery Audit Contractor audits, or RACs. The purpose of these audits and the program as a whole is to investigate and eliminate any Medicare or Medicaid discrepancies and decrease waste. The auditors themselves are independent contractors whose job is to look into the billing and record keeping practices of the dental office. They have the authority to check up to three years of records and report their findings directly to the CMS. An RAC audit can begin if a patient reports a problem or may be ordered at random if CMS has flagged the office as being at a high risk for errors.

The more serious form of a CMS audit is the Zone Program Integrity Contractor audits, or ZPICs. These audits are another step in the process if the CMS already has the office under investigation. For example, a whistleblower may have already alerted CMS to a potential problem at the office and CMS has already opened a case file. The purpose of the ZPIC is more prosecutorial than a RAC audit. Where the RAC can serve as a sort of cautionary audit to prevent instances of waste, a ZPIC takes place for the purpose of gathering evidence to build a fraud case. A ZPIC auditor even has the authority to suspend a dentist’s relationship with Medicare or Medicaid if they believe that the dentist is not being forthright during the audit.

Other forms of audits are internal at Medicare or Medicaid. While these audits may not immediately affect a dentist or their practice, they could uncover evidence that may lead to the more invasive forms of audits. For instance, Medicare Administrative Contractors, or MACs, oversee claims made under Medicare. These auditors mainly work to issue payments following dentist claim, but also have the responsibility to report any apparent discrepancies found in their process.

Overseeing these workers are the Comprehensive Error Rate Testing auditors. These CERTs function as supervisors to the MACs and may uncover impropriety that could be traced back to a dentist’s office. A dental audit lawyer could help dentists to understand the forms of audits and how they may affect their practice.

What to Expect During an Audit

An Audit can be an invasive and uncomfortable experience. Any audit agent, whether they are employed as RAC or ZPIC, has the authority to examine all the financial and record keeping aspects of a dentist’s business.

This most directly affects a dentist’s billing practices with Medicare and Medicaid. RAC auditors can examine every billing transaction and medical record tracing back over a period of three years. ZPIC investigators have no time or volume limits in their investigations.

As a result, dentists will have to provide all their office’s records upon auditor request. However, this does not mean that a dentist should offer this information without consulting an attorney so as to protect their rights.

A dentist audit lawyer can help protect the practice during the audit.

Potential Results from an Audit

In general, a dental audit concerning Medicare or Medicaid can end in one of three ways. Naturally, the most desirable outcome is for the auditor to find no evidence of any attempts to defraud the government. Any billing discrepancies may be mere mistakes, or a reporting party may have been mistaken as to what they believed that led to the audit. This is most common in RAC audits.

The second potential outcome may find that errors did occur, but the auditor stops short of recommending criminal or civil charges. This can be the result of an isolated incident where the payment of an administrative fine is recommended by the auditor as the best option moving forward.

The most serious result for any dental audit is the recommendation by the auditor that a prosecutor file federal charges. At this stage, a dentist’s priorities shift from damage control for the practice to concern over protecting their future. A criminal conviction could result in fines, the loss of a professional license, or even a prison sentence. A dental audit lawyer could help people to comprehend the possible outcomes of dental audit.

When an Audit Results in Criminal Charges

Of course, the outcome that should be cause for the highest level of concern is when an auditor recommends that a prosecutor pursue criminal charges. These charges typically allege that a defendant-dentist participated in a scheme to defraud the federal government. Medicare and Medicaid are federally-funded healthcare programs, so any attempt to intentionally file a false claim or to mislead these programs is a serious offense.

The most prominent example of a civil charge that may result from a dental audit is a violation of the False Claims Act. According to 31 U.S.C. 3729, it is illegal for any person or business knowingly to make a false or misleading statement to the federal government for the purpose of obtaining any payment from the government. Therefore, if a prosecutor can prove that a dentist intentionally double charged one patient for a single procedure, and submitted this claim to Medicare or Medicaid, this may certainly be grounds for prosecution.

Under the False Claims Act itself, Dentists could face treble damage or civil fines. Of course, the Federal Government also has the option to pursue conduct in criminal court.

Prosecutors could also allege that a defendant violated the Social Security Act. Much like the False Claims Act, 42 U.S.C. 1320a-7b says that it is illegal for any person to it is illegal to knowingly make any false statement in any application for a payment under a Federal benefit plan. This applies to both patients who may attempt to charge a cost to Medicare without authorization and a dentist who attempts to collect payment. A dental audit lawyer could work for dentists facing audit to understand the potential criminal complications that may arise and to develop an effective courtroom strategy.

A Dental Audit Lawyer Could Help Protect You

Receiving news that your dental practice is to be the subject of an audit is difficult to bear. At the least, this audit will dig into the financial and medical records of your practice for the past three years. More invasive audits may examine all the transactions that your practice has ever had with patients, Medicare and Medicaid.

If the audit does uncover evidence of fraud, this may lead to serious federal charges. These charges may allege that you intended to defraud the government out of payments for services that you never provided to patients. The penalties for a conviction can range from the payment of fines, to the loss of membership in the Medicare or Medicaid providers’ program, to a prison sentence. It is also a strong possibility that your State’s dental licensing board will move to suspend or revoke your license to practice.

A dental audit lawyer could help to protect your rights every step of the way. From the day that you receive notice of a pending audit, an attorney could help to organize your records to cooperate with the auditor as required by law. If the audit does recommend disciplinary action or even criminal charges, a dental audit lawyer could help to defend you and your ability to continue to practice dentistry. The stakes could not be higher; contact a dental audit lawyer today to hear how they might be able to help you.