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Probity: Why me?

04 May 2022

The trend towards checks and balances in dental funding systems has increased worldwide over the years. This means that dentists who participate in such schemes may face greater accountability and see an increase in the level of scrutiny that results in the receipt of more correspondence relating to different aspects of their provision of treatment.

While it is often said that professional people who are ethical and honest have nothing to fear from such investigations, Dental Protection’s experience is that many professionals feel threatened by the process, particularly when they are conducted in a very formal manner.

Why me?

Probity in itself is not something to be feared. In general the funding scheme needs to be able to check that the claims being made are justified and correct. Probity checks can be random or targeted, with targeted checks sometimes focusing on practitioners who find themselves outside the statistical norm for a certain type of treatment. There can be areas where the narrative of a contract relating to a particular form of treatment could be open to different interpretations. If a practitioner misinterprets a particular item of care in a fee scale for a short period of time then that may not cause too much of a problem. However, if such misinterpretation continues for a number of years, then it may involve a considerable sum of money. A probity investigation that challenges the claims made could result in a demand for return of fees, or a full scale contractual dispute, or even a fraud investigation, or a Dental Council referral. 

Non-negotiable

In some jurisdictions practitioners have found themselves in considerable difficulty when there have been claims for treatment that was not provided. Those of a cynical persuasion might take the view that the practitioner had chosen to make an adjustment to the level of fees associated with their own particular contract - believing it to be too low. For example, claiming for a surgical extraction when the procedure was actually less complex.

Tips

Understand the contract

It sounds easy, however the terminology used in contractual documentation is not always clear. The technique of making a claim and waiting to see whether or not it is paid prior to making other similar claims is not recommended. Most payment schemes work on the basis that all the claims submitted will be justified and correct and probity checks are carried out retrospectively, normally on a sample of claims. The Irish Dental Association is well placed to provide advice on interpretation of the DTSS contract.

Evidence

It is important to be able to justify any claim that has been made. Poor clinical records are of no help when an examining dentist is trying to establish whether the treatment claimed for was justified, and a practitioner is trying to demonstrate his or her treatment rationale. Clear records that demonstrate diagnosis, treatment plans, discussions, details of treatment provided (and treatment not provided) and follow-up, are extremely helpful for demonstrating professional credibility.

Check carefully

Some dentists allow members of their team to complete forms for payment via various payment schemes. If that is the practitioner’s choice then it is acceptable but the overall responsibility for the veracity of the claim remains with the practitioner who must check the form for accuracy prior to signing it and submitting it. It is no defence to say ‘I just signed the form’.

Claim accurately

It is assumed that practitioners will make appropriate and truthful claims. Submitting a claim in the knowledge that the information on a claim form is incorrect destroys professional credibility and could lead to a variety of proceedings against an individual contractor.

Take advice

Members should always take advice from Dental Protection before responding to any
inquiry in relation to a probity issue. 

Please note: Dental Protection does not maintain this article and therefore the advice given may be incorrect or out of date, and may not constitute a definitive or complete statement of the legal, regulatory and/or clinical environment. MPS accepts no responsibility for the accuracy or completeness of the advice given, in particular where the legal, regulatory and/or clinical environment has changed. Articles are not intended to constitute advice in any specific situation, and if you are a member you should contact Dental Protection for tailored advice. All implied warranties and conditions are excluded, to the maximum extent permitted by law.