Where This Happens
Common Questions Teresa Receives
ADA Code of Ethics
2021 Wish For You
Michelle Strange: A Tale of Two Hygienists presents this week’s TIPisode: quick and easy tips to keep you up to date and presented by the experts in the profession. Now, get ready for your unofficial TIPisode.
Teresa Duncan: Hi. This is Teresa Duncan of the Nobody Told Me That! podcast and also the Chew on This podcast with my co-host Kevin Henry. They can both be found on the Dental Podcast Network.
I wanted to talk to you today about operating ethically in the dental environment. One of the questions that I’ll get, typically, after a class is “I just want to run this by you. Does this sound okay to you?”
Let’s expand on that a little bit. And I’ll tell you, also, that I will usually get this question — it’ll be quiet. The person will usually be the last one to come up to me in the room because they want to make sure that it’s private when they talk to me about it. Or I’ll get an email, you know, can we talk about this? Or there might be the last person on the zoom training call, and they just want to wait until everybody is gone so they can ask me this question.
So, if this sounds something like what’s going through your head, let’s talk about this a little bit. If you have to wait to ask your question when nobody else is around, that’s kind of a tip-off that you’re uneasy about the situation, and that you think bringing it up is going to be more trouble than it’s worth, and you just don’t want to get into it with the rest of your team. But then you go home, and then you feel like there’s something that’s just nagging at you. That is typically — those are your ethics.
So let’s talk about why I get these questions. Well, there are decisions that are made all over the practice all day long. You know this. You have clinical decisions. Up front, my team, the ones who are admins, we have to make administrative decisions. Sometimes those decisions aren’t in line either because they haven’t been discussed ahead of time or there’s just something else funky going on. Hopefully, there’s nothing else funky going on.
And, to be fair, most of the questions that I get, it’s probably only about a quarter of the time where something is really wrong. The other part of it is that it just hasn’t been explained to you, which is really not a fault of yours. Honestly, as a manager, I always wanted to make sure that my team understood why we did certain things rather than just push it on you and just say “because I said so.” That’s really no way to manage, right? I think you all know that.
So let’s talk about where this happens. Well, I hate to say it, but most of the time if you tell me you work in a Medicaid practice, there’s going to be a little bit of eyebrow raising. And I just hate to say it, but it’s based on prior experience. A lot of the mistakes are made at the Medicaid office level, and it is because the numbers are so low. The reimbursements are very low, and you have to be high volume.
Not only in that environment is there trouble because you are running so fast all the time, there’s always going to be a risk of a wrong code being put in or a wrong amount. When you’re on a hamster wheel, it’s really hard to catch mistakes. That could be one reason, or it could be something more insidious. And I hate to tell you this, but there are a lot of doctors out there — they’re a minority, but there are a lot of doctors out there who have no problem committing, you know, fraud, you know, using codes and against patients in order to take home some extra money.
I hate to think that our industry is like that. And, again, it’s a small percentage. But every industry has it. We hear all the time about people being defrauded or stolen from. And, unfortunately, we have always bad apples in every industry.
Let’s talk about some of the common questions that I get. One is the hygienist will say to me — let’s just take every question is going to be from a hygienist to me about administrative behaviors, so let’s just set that standard there.
First things first. “Uh, she changed my code. I’m not sure why she changed my code. It just doesn’t feel right. I did a prophy, and every time I go up there, it’s changed to either a 4346 or a 4910. That doesn’t feel right.” So the answer to this is we always code for what you did. You being the clinician, you know what you did. You write it down in the chart. If you know which code fits it more appropriately, that’s of course the code that we’re going to use.
From an administrative standpoint, I cannot change your code. It’s not on me to decide what the code is. It’s on you to decide what the procedure was, what you did, document it, and then, you know, you should know which code it is. I’m checking it up front. Now, if you ask me what I think the code is, we can go over it, but I’m not the one who can go in and change codes after the fact. That’s not really a team environment.
My question to this particular hygienist was “Do they come back and talk to you about it?” And she said no. She runs it on her production, and she sees that it’s been changed. Now, she hesitated to come to me because she noticed — she was paid on production — she noticed that her numbers were higher. So I understood where she was coming from, but the reality is she was performing services, claimed one thing, and another code was sent in.
Could that come back to haunt her? You know, there are cases where they’ve tried. I don’t know of any cases where they’ve successfully done this when it’s been on, you know, not a routine basis. There are some offices that do it routinely. If it’s just a one-off basis that can be attributed to a mistake, however, I don’t want you to have to do that kind of rationalizing. I want you to code for what you did.
So my advice to this hygienist was “I know that the extra production is going to hurt. I know losing that is going to hurt. But you have to be honest about this.” So I would go back, and I would talk to my admin and ask them, you know, “Here’s my dates of service that I’m concerned with. I don’t think I did these procedures. Can you give me a reason why?” And, you know, not to attack them. Not to say, “You changed these procedure codes.” You could say, “I don’t think this is what I did. It doesn’t match my notes. Could you help me understand why?”
We never want to ask these types of questions with an accusatory tone, but we do want to be firm about what you’re asking. And I don’t lead with “Well, I think you did this.” I don’t lead with that. I lead with the facts. I let them know this is what I found. Can we understand this together? I know that it sounds like semantics, but when you’re going up against someone who possibly is not being ethical, it’s a really difficult conversation on its own. So want to make sure that it doesn’t blow up on you before you can even get an answer.
The other question that I get is “I’m not allowed to take xrays unless there’s coverage with the insurance.” And that’s not right. This one particular hygienist was telling me that she’d love to do the FMXs as needed, she would love to do bitewings on her return patients as needed, but there were strict rules in the morning huddle when they can take xrays and when they can’t, and it was all dictated by insurance.
In your core, you know this is wrong. You know that xrays are individually prescribed based on the patient’s risk and presenting condition, right? We know that. The admin team knows that. So why are they being told to take xrays at certain intervals? Obviously, it’s because insurance carriers are going to benefit for this. But I don’t know why an admin team member is telling you when you can and can’t take xrays. From an admin team member, that’s not appropriate. I’m not the one in charge of the patient’s care. I’m not the one that’s taking a look in the mouth. That’s all on you, and we should be trusting you to make those decisions, also the doctor — in conjunction with the doctor, of course.
When you are only taking a look at the patient’s benefits and deciding that’s when they get xrays, you know you’re doing a disservice to the patient. I would definitely speak up on that because not only is that unethical, it’s just flat out clinically not indicated. It’s wrong. And this particular hygienist was telling me that even if the patient doesn’t need it, they would be asked to take xrays, and she was very uncomfortable because she knew that the person didn’t need xrays. They were fine. But it was there on the morning huddle, and if she didn’t take the xrays, then she got into trouble.
Okay. Another question that I received — and I remember this lady’s face very plainly because she just was — she was dealing with a lot. You know, this wasn’t the only thing that was going on. And bless her heart. She really needed one of those conversations after classes where we both just sit down in a chair and she just unloads.
Here is what her question was: “I see that they’re changing dates on the claim form because they know that the person didn’t have coverage on that date, and so they change the dates.” This happens a lot right about now. You guys have probably noticed, you know, we’re towards the beginning of the year. Some of you saw it in the end of 2020. People will change the dates of procedures because they think they’re doing the patient a favor and letting them have the coverage.
Here’s the thing. I have seen this often where they just want to do a solid for the patient, and I understand it’s all about customer service, but you can’t break the rules of ethics in order to provide that customer service. The patient’s plan is the patient’s plan. If they don’t allow crowns on a certain date because maybe they’d maxed out or whatever the reason is, that is not on you. That’s not on the office to take that burden. That’s the patient’s decision. The patient can decide to proceed, pay out of pocket, or the patient can decide to wait and pay for it in January. That’s the patient’s decision. You know, I can’t make that decision for them. I can only present to them what needs to be done and what are the financial options. But changing the dates to get coverage is 100 percent insurance fraud.
You know, think about it this way. You might be doing something — not you. The admin team might be doing something nice for the patient. They think they’re doing the patient a favor. What happens if the patient contests it? What happens if the patient calls the insurance company and insists that she was seen in December not in January and your records it was December not in January? The only thing that’s different is the claim form. Well, guess who’s in a lot of trouble? The office. Guess who is going to have to explain that and pay the money back and possibly lose any participation status if they have any? Just don’t do it.
So, if you see this going on in your office, I would urge them to take a look at the ADA’s Code of Ethics. In fact, this is something that I think everybody needs to take a look at. It’s available for free. If you search “ADA Code of Ethics,” you’ll find it on the site.
Okay. I get another question here where the patient will have a PPO plan, and you’re participating providers. Let’s just say that. And then I’ll just — one aside. PPO plans squeeze the providers a lot, and so in those particular offices you see a lot of rationalization of why they do what they do. You see a lot of offices saying, “Well, we’re going to take all these extra xrays and get paid for them because we’re not going to get paid as much as we should on the crown.” That’s not the point. That’s not the point. When you sign the contract to accept those fees, those are the fees. And, unfortunately, unless you get out of the contract, you are obliged to serve with the contract. That is the contract that you signed.
Okay. So let’s get back to charging the patients differently. So what I hear often is the PPO patients will get charged for a crown — let’s take a crown for example because this is the most common example that I can think of. I hear this all the time: “Well, for our PPO patients with the crown, they always charge them extra fees, and they don’t submit them to the insurance company. But then, when I get a regular fee-for-service patient, we don’t charge them those other fees. It’s just the crown. I don’t think it’s right that the PPO patients should have to pay an extra fee just because they’re in a PPO.” Now, that’s usually the concern. I hear this all the time. And it is, again, not — it’s not cool.
In the ADA Code of Ethics they have specific conversations about how to charge patients. And, really, the bottom line is that the patients should be treated equally. And the only difference in that is if you sign a contract allowing them to get different, lower fees. That’s the only difference. But you have to treat patients the same. They cannot be discriminated against. And, in this case if they’re PPO patients, you’re basically changing the fee and charging them more. So, unfortunately, I hear this a lot.
The other — we’ll just finish with the last one, which is alternating 4010 and 1110 not because the clinical team thinks that it should be alternated but under the guise of obtaining more payment for the patient. And I understand — again, to me, I see this all the time. The admin team thinks that they’re doing a favor for the patient. They think the patient’s going to appreciate it. I will tell you from years of doing this or working with offices that do this that patients really don’t care. They don’t — you know why they don’t care? They don’t know. A lot of times we don’t tell the patient that we’re doing that. So the patient doesn’t understand it.
I would urge you to — when you present your treatment plans for scaling and root planning, make sure — and this is something you could do too during the actual procedures. Make sure that they know that every procedure after that is going to be the perio maintenance as per your clinical decision, as per the dentist’s clinical decision. They just are not going to alternate. They shouldn’t alternate. I know that there’s a lot of people out there that will say it’s okay to alternate it. I firmly believe — in talking to a lot of other periodontists, I firmly believe it’s not an alternatable, if that’s a word, code.
But let me bring this home. If they are doing this, again, without your knowledge, yes that can impact your production. So, if you’re charging 4010 but yet they’re alternating the 1110s, that’s alternat — that’s impacting your production and your collection if you are paid out on a percentage. So you do need to pay attention to that.
Now, let’s talk about that real quick, and then we’ll go ahead and wrap it up. Are you running your reports? Now, if you’re being paid hourly, I understand that there’s not the incentive. You’re kind of thinking, “Eh. Why would I run my reports? You know, I’m getting paid per hour.” I would just urge you. Take a look at what is being done in your name. You guys have provider ID numbers for a reason. You know, you are also part of the claim form. Should it come to pass if there’s any kind of audit that’s being done, they’re going to look at the chart, and guess who is in the chart? You. I would just urge you to make sure that everything that has any contact with your name, anything that your name is attached to, I want you to make sure that it’s on the up and up and that you won’t have any trouble with it. If I were a hygienist, this is something I would absolutely do.
And, actually, if I were any clinical team member, I would absolutely take a look at the records and see what was billed out under my tax ID number; under my NPI number, the National Provider Identifier; under my clinical notes. I want to make sure that I’m represented fairly and also truthfully because I don’t want to ever be the test case for any kind of audit or any kind of prosecution. That’s not what I want in life. So I hope — I’m sure that that’s not something that you’re aspiring too as well.
Let’s go ahead and end this by saying that if you feel that something is not right with what’s going on in the office, take a look at it first before you bring it up, and then bring it up as you have found this information, it doesn’t gel with what you normally see or what you normally do. Can I get some understanding as to why this is coming out differently? Again, don’t make it personal. You’re looking for the reasons. And, hopefully, it’s just something where it’s been a miscommunication. Hopefully, it becomes an educational moment for the both of you.
But the reality is you may not have that situation. You may have a situation where something is not going to sit right with you. I can’t counsel you on what to do in a TIPisode, but I would say that you have to take a look at what Code of Ethics you’re governed by. Whether it’s the ADA, the ADHA, you have to take a look at your Code of Ethics and also your personal code of ethics. If it doesn’t sit right with you now, I can tell you from experience it will not sit right with you down the road. In fact, it will become an even worse cross to bear.
So just take a good look at that, and hopefully, hopefully, this will never be an issue for you because you’re going to work in an office that’s going to do everything by the book. That’s my 2021 wish for you and every other listener of A Tale of Two Hygienists.
My podcasts are Nobody Told Me That!, which does management and insurance, and I also talk a lot about leadership. And I co-host another podcast with Kevin Henry called Chew on This where we go over dental news. It can be a little bit funny sometimes, and I hope that you check them both out. You can find them both on the Dental Podcast Network.
Until the next TIPisode, thank you so much for listening to this one.
Michelle Strange: We hope you enjoyed this week’s TIPisode. Be sure to reach out to our guest experts and let them know how helpful their tips were. Follow A Tale of Two Hygienists on Facebook, Instagram, and head over to ataleoftwohygienists.com and subscribe to our newsletter. You can also email us at firstname.lastname@example.org, and keep listening for more awesome content from your unofficial dental hygiene podcast.
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