The Problem with Dental Audits: Why You Should Get Legal Representation Right Away
So much of the conversation about CMS audits of health care providers is focused on doctors, hospitals, and pharmacies. But dental practices are being targeted for Medicare and Medicaid audits with increasing frequency too, and pediatric dentists are at an especially high risk.
Of course, CMS isn’t the only agency casting scrutiny on dentists. According to a recent report by the American Academy of Pediatric Dentistry (AAPD), multiple federal law enforcement agencies have stepped up their investigations into potential health care fraud within the dental industry. Medicare and Medicaid audits are a part of that.
Pediatric dentists treat an especially high number of patients covered by Medicaid, and so CMS has identified pediatric dental audits as a potential source of overpayment. If the government (or its contractors) can identify CMS overpayments to these dentists, it can recoup that money, so there is a clear incentive to find evidence of errant billing or health care fraud.
Dental audits don’t always produce accurate findings, however. In fact, a high number of dentists’ Medicare / Medicaid audits are ultimately reversed in the appeals process. By then, though, damage has already been done.
Errors in the auditing process — or accusations of fraud that arise out of a very minor mistake or a wrongful accusation by a disgruntled patient or employee — can have an absolutely devastatingimpact on dentists and their practices.
If you are a dentist or work in a dental office that treats even one patient on Medicare or Medicaid, you should know that a dental audit could put your office in virtual gridlock for months or even years.
These audits can demand the production of countless documents dating back several years, and in some cases, they can even cause CMS to stop paying you for services already provided even before the auditors have concluded any debt or wrongdoing(e.g., “prepayment review”).
Even more concerning, if an audit implicates unethical or criminal behavior, in some cases those findings can be referred to other agencies, resulting in federal felony chargesand/or disciplinary action from the state licensing boards. Disciplinary actions can possibly include suspension or revocation of your dental license.
For these reasons, it is imperative that health care providers in this industry understand the relationship between dentists and Medicare / Medicaid audits. Below, we explain how to prepare for an audit, how to work toward the best possible outcome, and how an experienced dental audit attorney can help.
How Do Dental Medicaid Audits Unfold?
In most cases, a dental Medicaid audit begins as a desk audit, in which the dentist doesn’t even know that his or her practice is under audit or investigation until they receive a Draft Audit Report.
If you’ve received a Draft Audit Report, it might have come as a surprise, but nowis the time to take serious and aggressive action to protect yourself and your practice.
The report should detail the findings of the initial Medicaid audit, as well as any specific allegations of fraud. You have only 30 days from receipt of the notice (which the government interprets as 35 days from the date on your letter) to respond to the Draft Audit Report, and it is absolutely critical that you work closely with an experienced dental audits lawyer in preparing your response.
Your response is your chance to submit arguments, objections, and requests in answer to the government’s audit. In many cases, the right arguments and requests can bring an audit to an end without further investigation or consequence. Mistakes are easier to make than you may realize, so carefully answering will help you avoid making the situation even worse.
An experienced dental audit defense attorney can advise you as to the objections and requests that are most likely to be effective under your particular circumstances.
Auditors Don’t Always Understand the Difference Between “Sloppy” and “Fraudulent”
Some audits and investigations are carried out directly by federal law enforcement agencies and the offices they set up around the country. Others are performed by private corporations contracted by the government to uncover billing discrepancies.
In every audit, the auditors are expected to carefully follow procedure, operate in good faith, and comply with relevant federal policies. That’s especially true where criminal accusations like fraud are involved.
Fraud is an intentional act. To be convicted of fraud, you would need not only to have billed CMS for a service you didn’t provide (for example) but also to have intendedto perpetrate the fraud. Investigators are expected to know this, and dental audits should always be conducted with that standard in mind.
But federal law enforcement is eager to take tough stances and demonstrate its ability to “crack down” on apparent waste or abuse in the billing system. Accordingly, agents frequently equate sloppy billing with fraudulent billing.
As a dentist, you and your practice might be less than perfectly organized. You might have busy or short-staffed seasons were accidental mistakes get made. Those things are unfortunate, but they do not constitute fraud.
As federal health care defense attorneys, part of our job is defending dentists who’ve been unfairly accused of fraud after a Medicare or Medicaid audit. Innocent dentists have been charged in far too many cases, and when that happens, we’re here to fight back.
We want dentists to understand that, once an audit begins, the government can quickly make a federal case out of a clearly innocent mistake — quite literally. (And keep in mind that you might not even know an audit has begun!)
Other Common Problems in Dentist Medicaid Audits
The AAPD has identified several other key conflicts that put dentists at high risk of an unfair outcome after a Medicaid audit — especially if the dentist is not represented by an experienced attorney. Their core concerns include:
- Lack of dental expertise. When doctors get audited, the team of auditors assigned to their case will usually include a physician. Even then, the audits are frequently errant and unfair. But the situation is even more startling for dentists, because dental audits are rarelyconducted by other dentists. On the contrary, the auditors usually have no dental experience whatsoever. This puts them in a poor position to determine which treatments might have been medically necessary, for example, or whether a given billing practice was reasonable under the circumstances.
- Contingency fees. When third parties are hired to conduct an audit on the government’s behalf, federal law allows the contractor to keep a percentage of the money it collects. In other words, your auditor can make a profit by collecting money from you. The resulting conflict of interest is inherent and clear. The auditors’ financial incentive to work against you makes it all the more important that you have an experienced legal advocate on your side.
About Our Firm
Oberheiden, P.C.is a federal dental defense law firm with many years of experience in health care fraud cases. We represent dentists and other doctors all across the country, drawing on our deep experience as former federal prosecutors in health care fraud causes.
Attorney Nick Oberheiden, for example, is a former federal prosecutor who has since provided legal defense to high-profile doctors, dentists, health care executives, and even public officials, among many other clients. Dr. Oberheiden is the managing principal of Oberheiden, P.C., and he leads a team of legal veterans here who fight every day for the legal interests of medical entities and the care providers they employ.
At Oberheiden, P.C., our goal is to end audits and argue effectively against adverse determinations. In every case, we fight to:
- Bring audits and investigations to an end
- Keep your dental license intact
- Defend your professional reputation and good standing
- Preserve your ability to prescribe medications
- Minimize or avoid penalties, fees, and fines
- Prevent government overreach
- Keep your practice in business and treating patients during the course of an audit
We are available seven days a week (even on weekends) to talk about your case and how we might help.
Facing a Medicare / Medicaid Audit? Please Contact the Trusted Law Firm of Oberheiden, P.C. Right Away
If you are a dentist or manage a dental practice that is currently under a Medicare or Medicaid audit anywhere in the United States — or if you have been accused of health care fraud — please contact our office for guidance as quickly as possible.
The federal government moves quickly and aggressively when building a case against dentists, and it will use any evidence it can find against you. An experienced law firm can defend your rights and advance the most strategic arguments against any audit or investigation.
Compliance – Litigation – Defense
Dr. Nick Oberheiden has successfully represented healthcare executives and physicians – as well as businesses in the areas of toxicology, pharmacy, home health and hospice centers, DME, hospitals, surgery centers, neuro-monitoring, and blood and DNA testing centers – in healthcare compliance and defense.