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When your number is up

08 April 2019
Dr W was a recent graduate and looking for a permanent practice role. He had given a lot of consideration about the type of practice he wanted to work in.

He was seeking a group practice with plenty of other practitioners as he was concerned about professional isolation. Dr W was keen to be surrounded by likeminded colleagues to enable him to develop and grow. The practice did not have a principal dentist, but rather a ‘flat hierarchy’ of practitioners and a non-dentist practice owner.

On assessment, Dr W formed the view that the contract seemed fair and the practice seemed reasonably well equipped. The other dentists were all welcoming, and said that they had a good flow of patients, particularly new patient examinations, so made a good income.

He took the job. For the first few weeks, he kept a tight eye on his billings, and indeed, he had a steady flow of patients and a good income. With the passage of time, Dr W became more relaxed at the practice, as he was happy there, and had formed good relationships with both colleagues and patients alike.

He was surprised to receive a letter from the Health Fund, stating that he was an outlier and requesting validation for the number of codes charged per patient, and, the number of five surface fillings came as a surprise to Dr W who could not recall having placed many five surface fillings. The practice owner reassured Dr W that they would manage this on his behalf stating it was likely that the front office staff had entered the codes on the wrong provider number – a common administrative mistake, and that they would look into this and respond. Dr W did not seek advice from Dental Protection as he believed the matter to be ‘routine’ and in hand.

The second Health Fund letter followed quickly, with similar allegations to the first. Dr W again contacted the practice owner to alert them to the issue and seek some assistance. However, this time the practice owner did not respond in a helpful way, and Dr W felt quite threatened by their reaction. At this point, Dr W contacted Dental Protection, who advised him to look a little deeper and see what patients’ invoices cited. To Dr W’s horror, the HICAPS transactions did not reflect his clinical notes, with two surface fillings being invoiced as five surface fillings, patients being charged for teeth adjustments that Dr W had not undertaken, and most alarming, a recent crown not being visible in the invoice stream, having been replaced with an invoice for eight x five surface fillings instead.

When Dr W challenged the front office staff, they were nonplussed, calling him naïve, and advising him that the only way to treat patients fairly was to maximise their Health Fund rebates. They confirmed that they were working under the direction of the practice owner, and that their ‘fair billing’ policy attracted many patients.

Dr W was alarmed by these statements, and even more so when he realised that because the billings had gone through on his provider number, he was solely responsible for the repayment of all monies inappropriately claimed, back to the Health Fund.

Dental Protection assisted Dr W in responding to the Health Fund and also in leaving the practice.

Learning points
  • You are responsible for all items charged under your provider number, and as such should regularly review your HICAPS billings.
  • Take the time to close your provider number when you leave a practice to ensure that no inappropriate billings are put through on your number after you have left.

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.

None of ADA WA, DPL, DPLA and MPS are insurance companies. Dental Protection® is a registered trademark of MPS.