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When your number is up: A case involving provider numbers

28 July 2022

The announcement that dental hygienists, dental therapists and oral health therapists would be able to apply for a provider number and claim directly for services provided under the Child Dental Benefits Schedule (CDBS), with a planned commencement date of 1 July 2022,1 feels long overdue. We can all see the benefit of this change, but what are the risks? Dr Annalene Weston, Dentolegal Consultant at Dental Protection, finds out.

Provider numbers are in essence a site-specific fee claiming mechanism. Something so simple should not be contentious, and yet we see an alarming number of cases relating to the inappropriate use of a provider number. We wanted to highlight some of the risks relating to holding a provider number, in the hope that we can help you protect yourselves from the same issues.

Case study

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 and 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. The five-surface filling comment 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 the 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 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. These billings were in the tens of thousands of dollars.

Dental Protection assisted Dr W in responding to the Health Fund and Dr W subsequently moved on from the practice.

Learning points

This case is sadly not unique, with many practitioners finding codes are put through on their provider number or altered without their knowledge.

As the ‘owner’ of the provider number you are solely responsible for the codes billed. This means that regardless of the percentage you may have been paid for any treatment, if the money is clawed back by the third party who made the payment, 100% is clawed back from you, and you alone.

You are responsible for the accuracy and validity of all codes put through under your provider number. Make sure you regularly check your HICAPS receipts to ensure that the coding is correct. As the coding will be CDBS only at this stage, you can also check through PRODA.

Take the time to close off your provider number when you leave a practice to ensure that no inappropriate billing is put through on your provider number after you have left.

Provider numbers can be suspended or withdrawn if there is a continued pattern of inappropriate billing.

Want to know more on this issue? Listen to our RiskMatters podcast “Why are item numbers so important?” with Dr Annalene Weston and Dr David Hallett, CEO of ADAWA. The Dental Protection podcasts RiskBites, RiskMatters and CaseMatters are all available through our website and your regular podcast streaming platform.

1Provider Numbers for Oral Health Practitioners


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