17 - Prescribing patterns

A member received a letter from a government agency concerning the pattern of claims for advanced periodontal treatments. The dentist's practice profile suggested that claims under the category of advanced periodontal treatment were almost 50 times the average for the country as a whole.  Dental Protection assisted the member in replying, pointing out the criteria by which he selected patients for advanced periodontal treatment. The practitioner worked in an area where patients were from lower socio-economic groups with higher periodontal needs. 

Approximately six months later the dentist received a further letter demanding the sum of money for treatment provided under the appropriate code for a period of approximately three years. The dentist had been asked, within the provisions of the scheme, to seek prior approval approximately three months previously and no request for such treatments had been made in that period of time. The government agency took the view that the absence of claims in the three-month period preceding their letter suggested that all treatment that had been prescribed previously was unnecessary. The same government agency, without the authority of the dentist, had recovered some of the money from a monthly payment schedule. 

Dental Protection, on behalf of the dentist, disputed the action and questioned the agency¹s authority to recover the monies. A stern reply was received indicating that the agency was considering putting the matter into the hands of the police.  Following further discussions the practitioner did accept that there had been some misinterpretation of the fee scale narrative and the records, which the practitioner maintained, had not been sufficient to support the claims. In particular, there was very little periodontal charting on the clinical records. 

A meeting was held between the government agency and the dentist who was assisted by a dento-legal adviser. The constructive meeting resulted in the practitioner agreeing to repay a significant sum of money to the government agency.  The main reason why the claims could not be substantiated was that the practitioner's records simply did not have sufficient information to support the claim. The sum of money repaid was significantly less than the original sum of money requested.

This case highlights the importance of notifying Dental Protection at an early stage of a dispute with any fee-paying authority. Some authorities may choose to move matters in the direction of the police while other authorities e.g. Health Funds in Australia, may threaten the de-recognition of a particular practitioner for either all or certain types of treatment.

The case also highlights the importance of having clear and comprehensive records to be able to establish what treatment took place and to ensure that the dentist has complied with the rules of the fee payment system.

It also shows the benefit of resolving matters through discussion and dialogue and at a lower level. The timely involvement of Dental Protection in this case helped avoid a full scale police investigation which can be an extremely harassing procedure for any professional to undergo.