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