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Playing the numbers game

20 July 2018
By Dr N, Sydney

I have always wanted to be my own boss, so I set up my own practice straight from dental school.

Employing staff was a lot harder than I thought but I ended up with a mix of experienced staff and new people keen to learn. My practice manager was a great find. She was local, knew everyone and had recently left a practice when it was sold. She said she had the experience to help me build my practice. She seemed really nice, and the phone started ringing with patients as soon as she started.

I had prepared myself for a slow start, but I was busy straight away. I like making partial dentures and doing crowns, and I was happy with my business growth as I was doing a lot of prosthodontic work. I felt that patients were probably coming to me because I was cheap, but I hoped that with proven good quality work, I could grow by referral and see fewer people but charge more. 

The pace continued, and I began to rely on my staff more and more to do their job without being overseen. I began to work two surgeries simultaneously. 

Then I received a health fund audit. I thought this was just routine and sent the patient records as requested. I didn’t check who they were. I didn’t check their HICAPS receipts. I didn’t think about it again; I was too busy. 

Out of the blue, I received a letter advising me that the health fund had suspended my provider privileges – this meant that any patient who had health insurance from them would not be able to get a rebate if they saw me, AND they were going to write to every patient I had seen and tell them so. The letter also said that I needed to pay back a huge amount of money for incorrect billing. 

I contacted Dental Protection and they talked me through what to do. I got the patient records and compared them with the health fund records – they didn’t match. For example, if I had done a crown for 26, the patient had paid not for a crown on 26, but for five fillings instead – same money to me, less out of pocket for the patient, and one very unhappy health fund. 

I spoke to my practice manager to get an explanation. I thought she would be upset or apologetic, but she wasn’t. She said it was ‘standard practice’. She said that she was a ‘practice builder’, and that she was trying to help me. She said that the patients expected we do this. I knew that I could no longer trust her, so I asked her to leave. She threatened to destroy my business by bad mouthing me but it didn’t matter; I felt she had already destroyed it through dishonesty. 

I couldn’t believe that Dental Protection helped me, but they did. They helped me with a letter to the health fund to explain and they came to a meeting with the health fund and me. As a result of this, I got my provider recognition back, but I did have to pay back an amount for the dodgy billing. That was tough, particularly as it wasn’t me that did it, but I do understand it was billed under my provider number, and so it is my responsibility.

I now check all of the billings that go through HICAPS, because I can never, ever be in this situation again.

The dentolegal perspective

Dr Annalene Weston, dentolegal adviser for Dental Protection, Brisbane

I remember this case well. Dr N was just starting out: he is an honest and genuine practitioner who was devastated to be called dishonest, scared of reputational damage, and of losing the practice he had built up. I was glad we got such a good result.

I wish I could tell you that this type of case is in isolation but, regretfully, it is not. Many practitioners have their provider number used for inappropriate billing without their knowledge and, if this is discovered, it is the provider linked to the number who is responsible for the payback, not the person who has been billing.

The best practical advice we can give is:

  • Keep an eye on your billings through front office – don’t be scared to check the HICAPS receipts.
  • Never become involved in inappropriate billing practices – patients will ask you to run a different code (or a different card) through – don’t. 
  • Make sure you close a provider number when you leave a practice.

These case studies are based on real events and provided here as guidance. They do not constitute legal advice but are published to help members better understand how they might deal with certain situations. This is just one of the many benefits dental members enjoy as part of their subscription. 
For more detailed advice on any issues, contact us

© 2019 The Medical Protection Society Limited

DPL Australia Pty Ltd (“DPLA”) is registered in Australia with ABN 24 092 695 933. Dental Protection Limited (“DPL”) is registered in England (No. 2374160) and along with DPLA is part of the Medical Protection Society Limited (“MPS”) group of companies. MPS is registered in England (No. 00036142). Both DPL and MPS have their registered office at Level 19, The Shard, 32 London Bridge Street, London, SE1 9SG. DPL serves and supports the dental members of MPS. All the benefits of MPS membership are discretionary, as set out in MPS’s Memorandum and Articles of Association. “Dental Protection member” in Australia means a non-indemnity dental member of MPS. Dental Protection members may hold membership independently or in conjunction with membership of the Australian Dental Association (W.A. Branch) Inc. (“ADA WA”).

Dental Protection members who hold membership independently need to apply for, and where applicable maintain, an individual Dental Indemnity Policy underwritten by MDA National Insurance Pty Ltd (“MDA”), ABN 56 058 271 417, AFS Licence No. 238073. DPLA is a Corporate Authorised Representative of MDA with CAR No. 326134. For such Dental Protection members, by agreement with MDA, DPLA provides point-of-contact member services, case management and colleague-to-colleague support.

Dental Protection members who are also ADA WA members need to apply for, and where applicable maintain, an individual Dental Indemnity Policy underwritten by MDA, which is available in accordance with the provisions of ADA WA membership.

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