CDSCDS 238238 “Ethical Situations and “Ethical Situations and

the Law”the Law”

February 14, 2011February 14, 2011

Sharon P. Turner, DDS, JDSharon P. Turner, DDS, JD

Today’s TopicsToday’s Topics

Fraud in dental Fraud in dental practicepractice

Patient abandonment Patient abandonment in dental practicein dental practice

Healthcare Integrity Healthcare Integrity and Protection Data and Protection Data Base (HIPDB)Base (HIPDB)

National Practitioner National Practitioner Data Base (NPDB)Data Base (NPDB)

Learning GoalsLearning Goals Know the elements of Know the elements of

fraudfraud so as to recognize so as to recognize actions that are considered actions that are considered fraud in dental practicefraud in dental practice

Know the elements of Know the elements of patient abandonmentpatient abandonment so as so as to recognize actions that to recognize actions that are considered are considered abandonment of a patient abandonment of a patient in dental practicein dental practice

Know what the Know what the HIPDB HIPDB is is and how a dentist gets and how a dentist gets entered into this data bankentered into this data bank

Know what the Know what the NPDBNPDB is is and how a dentist gets and how a dentist gets entered into this data bankentered into this data bank

Integration of today’s topics into Integration of today’s topics into CDS 838CDS 838

Justice from a legal perspective Justice from a legal perspective means the proper administration means the proper administration of laws, similar wrong behavior of laws, similar wrong behavior gets similar punishment, fair gets similar punishment, fair handlinghandling

Justice from a bioethical Justice from a bioethical perspective instructs that benefits perspective instructs that benefits and burdens ought to be and burdens ought to be distributed equitably, scarce distributed equitably, scarce resources allocated fairly, one resources allocated fairly, one should act such that no one should act such that no one person or group bears a person or group bears a disproportionate share of burdens disproportionate share of burdens (distributive justice) or gains a (distributive justice) or gains a disproportionate share of benefitsdisproportionate share of benefits

Justice in general is associated Justice in general is associated with moral rightness or goodness with moral rightness or goodness in human actionsin human actions

Guiding ThoughtsGuiding Thoughts

Keeping the best interest of your Keeping the best interest of your patient always in mind will serve you patient always in mind will serve you wellwell

Always ask yourself if this treatment is Always ask yourself if this treatment is what you would want for yourself or what you would want for yourself or your familyyour family

There is honor in admitting that your There is honor in admitting that your outcome is not as desired and you outcome is not as desired and you want to correct the situationwant to correct the situation

Ignorance of the law is NO excuse!Ignorance of the law is NO excuse!

General Areas of the LawGeneral Areas of the Law

Criminal: Generally codified common law, but Criminal: Generally codified common law, but if there are gaps in statutes, go back to if there are gaps in statutes, go back to common law for meaning. Guilty (convicted) common law for meaning. Guilty (convicted) or innocent (acquitted). Fines or or innocent (acquitted). Fines or imprisonment, even loss of life. imprisonment, even loss of life.

Civil: Some is codified, but much is derived Civil: Some is codified, but much is derived from the publication of similar cases heard in from the publication of similar cases heard in appellate courts. Liability or no liability. appellate courts. Liability or no liability.

Administrative: Often takes the form of Administrative: Often takes the form of regulations. Completely statutory. Overseen regulations. Completely statutory. Overseen by agencies such at the KBDby agencies such at the KBD

Two Types of TortsTwo Types of Torts

NegligenceNegligence MistakeMistake Failure to meet the Failure to meet the

standard of care which is standard of care which is the duty that all health the duty that all health care providers have to care providers have to their patientstheir patients

Malpractice= Bad practiceMalpractice= Bad practice Elements=Duty, Breach, Elements=Duty, Breach,

Causation, DamagesCausation, Damages Expert establishes Expert establishes

standard of carestandard of care

IntentionalIntentional Action taken Action taken

purposefullypurposefully Intent may be inferred Intent may be inferred

if a person is “willfully if a person is “willfully ignorant”ignorant”

Battery, Fraud, Battery, Fraud, Abandonment, Abandonment, DefamationDefamation

Patient AbandonmentPatient Abandonment

The intentional, unilateral, The intentional, unilateral, nonconsensual termination of a nonconsensual termination of a dentist/ patient relationship before dentist/ patient relationship before completion of services agreed to or completion of services agreed to or necessary follow up has been necessary follow up has been performedperformed

Is intentional form of malpracticeIs intentional form of malpractice

Elements of AbandonmentElements of Abandonment Intentional or Intentional or

foreseeable from foreseeable from decisions madedecisions made

UnilateralUnilateral Nonconsensual Nonconsensual Termination of Termination of

relationshiprelationship Prior to completion of Prior to completion of

treatment agreed to or treatment agreed to or follow up required after follow up required after treatmenttreatment

Resulting in harm to the Resulting in harm to the patientpatient

Negligent DischargeNegligent Discharge

Different from abandonment in that Different from abandonment in that the decision to terminate care is the decision to terminate care is based on failure to use due care in based on failure to use due care in deciding that treatment or follow up deciding that treatment or follow up is no longer needed by the patientis no longer needed by the patient

Is negligent form of malpracticeIs negligent form of malpractice

So what is the difference?So what is the difference?

You may still get sued in civil courtYou may still get sued in civil court You may still get disciplined by the Board You may still get disciplined by the Board

of Dentistry in an administrative of Dentistry in an administrative proceedingproceeding

Unlike in a negligence action where an Unlike in a negligence action where an expert witness is mandatory to establish expert witness is mandatory to establish breach of the standard of care, no expert breach of the standard of care, no expert witness is needed to prove abandonmentwitness is needed to prove abandonment

Your malpractice insurance may not, Your malpractice insurance may not, probably will not, cover an probably will not, cover an intentionalintentional form form of malpractice if you lose in litigation!of malpractice if you lose in litigation!

DUTIESDUTIES

PATIENTPATIENT CooperationCooperation Keep appointmentsKeep appointments Follow adviceFollow advice Take medicationTake medication Pay for servicesPay for services

DENTISTDENTIST Complete treatmentComplete treatment In timely fashionIn timely fashion Acceptable qualityAcceptable quality Follow up afterwards Follow up afterwards

as neededas needed Refer to a specialist for Refer to a specialist for

treatment beyond the treatment beyond the scope/skillscope/skill

Maintain current skill Maintain current skill and knowledgeand knowledge

Examples of Abandonment from Examples of Abandonment from Actual LitigationActual Litigation

Unqualified refusal to further attend to patientUnqualified refusal to further attend to patient Express declaration or statement of withdrawalExpress declaration or statement of withdrawal Leaving patient during or immediately after an Leaving patient during or immediately after an

operation or procedureoperation or procedure Failure to attend to a patient despite a promise to do Failure to attend to a patient despite a promise to do

soso Unexplained failure to continue attending to patientUnexplained failure to continue attending to patient Refusal to treat a patient at a specific time or placeRefusal to treat a patient at a specific time or place Undertaking care that is beyond skill level and not Undertaking care that is beyond skill level and not

rapidly placing the patient in the hands of a specialistrapidly placing the patient in the hands of a specialist

Dicke v. GravesDicke v. Graves668 P.2d 189 (Kan.App. 1983)668 P.2d 189 (Kan.App. 1983)

Facts:Facts: Mrs. Graves was a patient of Dr. Dicke from 1974 Mrs. Graves was a patient of Dr. Dicke from 1974

until 1979. She had a difficult dental history, with until 1979. She had a difficult dental history, with complex and continuing problems. She had complex and continuing problems. She had experienced complete restoration of all of her experienced complete restoration of all of her teeth which was complicated by TMJ disorders, jaw teeth which was complicated by TMJ disorders, jaw thrust, and sensitivity to electrolytic interactions. thrust, and sensitivity to electrolytic interactions. In 1979 she reported and Dr. Dicke confirmed In 1979 she reported and Dr. Dicke confirmed fractures in her porcelain bridgework. X-rays were fractures in her porcelain bridgework. X-rays were made and no other problems were disclosed. made and no other problems were disclosed.

Two weeks later she complained of a toothache Two weeks later she complained of a toothache and Dr. Dicke noted movement of the bridgework and Dr. Dicke noted movement of the bridgework and concluded there were stress fractures in and concluded there were stress fractures in bridge and that she would required a repeat bridge and that she would required a repeat complete restoration of her teeth. complete restoration of her teeth.

Dicke v. GravesDicke v. GravesContinuedContinued

Six weeks later impressions were taken to Six weeks later impressions were taken to determine a recommended compete restorative determine a recommended compete restorative treatment approach.treatment approach.

Mrs. Graves continued to have discomfort. She Mrs. Graves continued to have discomfort. She and her husband made multiple telephone calls and her husband made multiple telephone calls and hand delivered a letter seeking rapid and hand delivered a letter seeking rapid commencement of treatment as she was in commencement of treatment as she was in continuous discomfort. Dr. Dicke did not respond.continuous discomfort. Dr. Dicke did not respond.

One month after hand delivering the letter to Dr. One month after hand delivering the letter to Dr. Dicke, Mrs. Graves sought treatment with another Dicke, Mrs. Graves sought treatment with another dentist who made the same diagnosis as Dr. Dicke dentist who made the same diagnosis as Dr. Dicke and immediately began the comprehensive and immediately began the comprehensive treatment which was completed in December. treatment which was completed in December.

Dicke v. GravesDicke v. GravesContinuedContinued

There was no complaint that any diagnoses There was no complaint that any diagnoses were flawed or that any of the treatment that were flawed or that any of the treatment that Dr. Dicke provided was deficient. (No alleged Dr. Dicke provided was deficient. (No alleged breach of the standard of care for diagnosis or breach of the standard of care for diagnosis or treatment.) treatment.)

Dr. Dicke sued Mrs. Graves (presumably for Dr. Dicke sued Mrs. Graves (presumably for nonpayment of services) and she nonpayment of services) and she counterclaimed for patient abandonment. counterclaimed for patient abandonment.

At the trial court level, the jury entered a At the trial court level, the jury entered a judgment against Dr. Dicke and he appealed. judgment against Dr. Dicke and he appealed.

Dicke v. GravesDicke v. GravesContinuedContinued

The issue which the appeals court The issue which the appeals court addressed was: Did Dr. Dicke withdraw addressed was: Did Dr. Dicke withdraw from the patient dentist relationship?from the patient dentist relationship?

The court determined that Dr. Dicke was The court determined that Dr. Dicke was non-diligent in his care, that is untimely, non-diligent in his care, that is untimely, delayed, inattentive all of which were if delayed, inattentive all of which were if anything negligent BUT NOT anything negligent BUT NOT ABANDONMENT. Therefore the trial court ABANDONMENT. Therefore the trial court judgment was reversed.judgment was reversed.

Lessons from Dicke v. GravesLessons from Dicke v. Graves Dr. Dicke was lucky that Mrs. Graves’ lawyer Dr. Dicke was lucky that Mrs. Graves’ lawyer

brought suit under the wrong cause of action and brought suit under the wrong cause of action and did not prove abandonment when negligence did not prove abandonment when negligence might well have been provable. You won’t always might well have been provable. You won’t always be lucky!be lucky!

Dr. Dicke probably got into this because he sued Dr. Dicke probably got into this because he sued Mrs. Graves for nonpayment. If you are going to Mrs. Graves for nonpayment. If you are going to sue for nonpayment, be sure that you have sue for nonpayment, be sure that you have “clean hands” yourself. “clean hands” yourself.

Legal cases are very fact specific. The jury or Legal cases are very fact specific. The jury or judge must take the unique facts in any case and judge must take the unique facts in any case and apply the appropriate law. A small change in facts apply the appropriate law. A small change in facts can render a very different outcome.can render a very different outcome.

Lessons from Dicke v. GravesLessons from Dicke v. GravesContinuedContinued

Respond to your patients in a timely mannerRespond to your patients in a timely manner If you do not wish to continue care or feel If you do not wish to continue care or feel

that the situation is beyond your skill level, that the situation is beyond your skill level, find another provider or a specialist to whom find another provider or a specialist to whom you can refer the patient in a timely manneryou can refer the patient in a timely manner

Never leave town without having someone Never leave town without having someone available to take call for you who has agreed available to take call for you who has agreed to take call and having your office answering to take call and having your office answering machine or answering service clearly machine or answering service clearly instruct patients what steps to take should instruct patients what steps to take should they need dental services in your absencethey need dental services in your absence

How do I protect myself from How do I protect myself from liability for patient abandonment?liability for patient abandonment?

Review “patient duties”Review “patient duties” If a patient is not living up to the patient If a patient is not living up to the patient

duties and you ARE living up to yours, duties and you ARE living up to yours, consider termination of the patient/dentist consider termination of the patient/dentist relationship relationship

Terminate the relationship by letter, sent by Terminate the relationship by letter, sent by certified mail, return receipt requested. certified mail, return receipt requested. State the reason for the termination of the State the reason for the termination of the relationship. The reason cannot be a relationship. The reason cannot be a pretense intended to cover a discriminatory pretense intended to cover a discriminatory reason for termination of the relationship, reason for termination of the relationship, e.g., HIV statuse.g., HIV status

Protections from Abandonment Protections from Abandonment Actions con’tActions con’t

Provide a 30 day period (or whatever is Provide a 30 day period (or whatever is reasonable for the situation, not less than reasonable for the situation, not less than 30 days) during which you will be available 30 days) during which you will be available to provide emergency treatment.to provide emergency treatment.

Do not terminate care while a procedure is Do not terminate care while a procedure is ongoing, even if you do not think that you ongoing, even if you do not think that you will get paid. Finish the procedure and the will get paid. Finish the procedure and the required follow up first, then dismiss the required follow up first, then dismiss the patient. Special considerations for patient. Special considerations for orthodontic cases!orthodontic cases!

If a patient is overdue for If a patient is overdue for recall, has failed to come recall, has failed to come

back to get definitive crown back to get definitive crown placed, write the patient a placed, write the patient a

letter and place a copy in the letter and place a copy in the chartchart

What about “dentist What about “dentist abandonment?”abandonment?”

Fraud in Dental PracticeFraud in Dental Practice

An intentional perversion of the truth An intentional perversion of the truth for the purpose of inducing another for the purpose of inducing another in reliance upon it to part with some in reliance upon it to part with some valuable thing belonging to him or to valuable thing belonging to him or to surrender a legal right.surrender a legal right.

The false representation of a matter The false representation of a matter of fact by words or conduct, false or of fact by words or conduct, false or misleading allegations or misleading allegations or concealment of that which should concealment of that which should have been disclosed. have been disclosed.

Elements of FraudElements of Fraud Representation of something as fact or omission Representation of something as fact or omission

thereofthereof That is material (essential) to decision-making or That is material (essential) to decision-making or

actionaction That is falseThat is false That the presenter knows it is falseThat the presenter knows it is false That the presenter intends it to be acted uponThat the presenter intends it to be acted upon That the person to whom the fact is represented does That the person to whom the fact is represented does

not know is falsenot know is false That the person to whom the fact is represented relies That the person to whom the fact is represented relies

upon in taking actionupon in taking action That the person has a right to rely upon the That the person has a right to rely upon the

representation due to relationshiprepresentation due to relationship That the actor suffers damage of a consequence of That the actor suffers damage of a consequence of

reliance and action upon the false informationreliance and action upon the false information

Examples of Fraud in Dental Examples of Fraud in Dental PracticePractice

Telling an untruth to induce a patient to have a Telling an untruth to induce a patient to have a treatmenttreatment

““Up coding” a procedure, i.e. MO becomes MOD Up coding” a procedure, i.e. MO becomes MOD or all extractions are “surgical extractions”or all extractions are “surgical extractions”

Billing for procedures never performedBilling for procedures never performed Billing for services not yet completed even upon Billing for services not yet completed even upon

patient requestpatient request Overbilling/double billing (see Nov. 2004 Overbilling/double billing (see Nov. 2004 AGDAGD

ImpactImpact, p. 14, “Top clinician questions esthetic , p. 14, “Top clinician questions esthetic dentistry over treatment” dentistry over treatment”

Dr. Gordon ChristensenDr. Gordon Christensen Waiver of an insurance co-payment or Waiver of an insurance co-payment or

deductibledeductible

Examples of Fraud in Dental Examples of Fraud in Dental Practice (con’t)Practice (con’t)

Charging different fees (higher) to insured Charging different fees (higher) to insured patients than to self pay patients patients than to self pay patients systematicallysystematically

Alternation and/or destruction of recordsAlternation and/or destruction of records Making false entries into recordsMaking false entries into records Providing false or purposely incomplete Providing false or purposely incomplete

information to a licensure board, information to a licensure board, credentialing office or third party payercredentialing office or third party payer

Billing for work done by someone else, i.e. Billing for work done by someone else, i.e. attending billing for work done by resident attending billing for work done by resident when attending is not present for “critical when attending is not present for “critical parts of the procedure”parts of the procedure”

Miller v. Commonwealth of Miller v. Commonwealth of Pennsylvania, State Dental CouncilPennsylvania, State Dental Council

(Pa.Cmwlth, 396 A. 2d 83, 1979)(Pa.Cmwlth, 396 A. 2d 83, 1979)

Facts:Facts: Dr. Miller owned a sole proprietorship dental Dr. Miller owned a sole proprietorship dental

practice specializing in oral and maxillofacial practice specializing in oral and maxillofacial surgery. He had three other oral surgeons working surgery. He had three other oral surgeons working in his clinic, presumably as independent contractors in his clinic, presumably as independent contractors rather than employees. An investigation and review rather than employees. An investigation and review conducted by representatives of Pennsylvania Blue conducted by representatives of Pennsylvania Blue Shield of those persons or institutions receiving Shield of those persons or institutions receiving more than $10,000 in payment for oral surgery more than $10,000 in payment for oral surgery services for any specific year revealed numerous services for any specific year revealed numerous discrepancies at the Miller Clinic. discrepancies at the Miller Clinic.

Miller v. CommonwealthMiller v. CommonwealthContinuedContinued

The insurance company reported these The insurance company reported these discrepancies to the Council, which discrepancies to the Council, which issued citations charging the 4 surgeons issued citations charging the 4 surgeons with filing false claims in violation of the with filing false claims in violation of the law prohibiting fraudulent or unlawful law prohibiting fraudulent or unlawful practices or fraudulent misleading or practices or fraudulent misleading or deceptive representations and deceptive representations and unprofessional conduct detrimental to unprofessional conduct detrimental to the public health, safety, morals or the public health, safety, morals or welfare.welfare.

Miller v. CommonwealthMiller v. CommonwealthContinuedContinued

The surgeons were sited for submitting The surgeons were sited for submitting claims to Blue Shield for the removal of claims to Blue Shield for the removal of impacted teeth, when, in fact, the Council impacted teeth, when, in fact, the Council found that the x-rays and other documents found that the x-rays and other documents available to them indicated that the teeth available to them indicated that the teeth extracted were NOT impacted. More than extracted were NOT impacted. More than 100 such discrepancies were documented. 100 such discrepancies were documented.

Blue Shield coverage excluded coverage for Blue Shield coverage excluded coverage for oral surgical services related to the oral surgical services related to the extraction of teeth other than fully or extraction of teeth other than fully or partially impacted teeth.partially impacted teeth.

Miller v. CommonwealthMiller v. CommonwealthContinuedContinued

Each of the surgeons had executed an authorization Each of the surgeons had executed an authorization agreement accepting full responsibility for all agreement accepting full responsibility for all statements, representations, and certifications statements, representations, and certifications appearing on all claims submitted to Pennsylvania appearing on all claims submitted to Pennsylvania Blue ShieldBlue Shield

The surgeon who preformed the treatment was The surgeon who preformed the treatment was responsible for listing the exact operative procedure responsible for listing the exact operative procedure on the patient’s chart.on the patient’s chart.

After 4 days of extensive hearings, the Council After 4 days of extensive hearings, the Council ordered suspension of the licenses to practice of all 4 ordered suspension of the licenses to practice of all 4 surgeons for 3 months for the nonowners and 6 surgeons for 3 months for the nonowners and 6 months for the clinic owner for fraudulent and months for the clinic owner for fraudulent and unlawful practices.unlawful practices.

The 4 surgeons appealed the suspensions of their The 4 surgeons appealed the suspensions of their licenses. The owner’s appeal was handled separately licenses. The owner’s appeal was handled separately from that of the 3 other surgeons. from that of the 3 other surgeons.

Miller v. CommonwealthMiller v. CommonwealthContinuedContinued

On appeal the surgeons argued that it wasn’t their On appeal the surgeons argued that it wasn’t their fault, it was the clerks who processed the claim fault, it was the clerks who processed the claim forms! The court responded that this “argument forms! The court responded that this “argument seems almost ludicrous in view of the fact that seems almost ludicrous in view of the fact that they assumed full responsibility for all information they assumed full responsibility for all information submitted over their signature stamps.”submitted over their signature stamps.”

They also argued that they shouldn’t be charged They also argued that they shouldn’t be charged with “knowing the claims were false.” The court with “knowing the claims were false.” The court found that the practice at the clinic indicated at found that the practice at the clinic indicated at the very least a “reckless ignorance” and in fact the very least a “reckless ignorance” and in fact the evidence did indicate that they had actual the evidence did indicate that they had actual knowledge of the falsity of the claims.knowledge of the falsity of the claims.

Miller v. CommonwealthMiller v. CommonwealthContinuedContinued

They also argued that they didn’t mean to They also argued that they didn’t mean to defraud to which the court responded, defraud to which the court responded, “Where the necessary consequence of an “Where the necessary consequence of an act is to defraud, it is no defense that the act is to defraud, it is no defense that the actor had no intention to cheat or defraud.” actor had no intention to cheat or defraud.”

They also argued that the Council had no They also argued that the Council had no jurisdiction of this matter since it did not jurisdiction of this matter since it did not involve a dentist/patient relationship and the involve a dentist/patient relationship and the insurance company had other remedies insurance company had other remedies available to it to which, in a beautiful available to it to which, in a beautiful description of the Council’s responsibility to description of the Council’s responsibility to protect the public, the court responded:protect the public, the court responded:

Miller v. CommonwealthMiller v. CommonwealthContinuedContinued

“…“…we are not here dealing with a civil suit we are not here dealing with a civil suit to enforce individual rights. Rather, we to enforce individual rights. Rather, we are dealing with an administrative are dealing with an administrative agency of the sovereign which seeks to agency of the sovereign which seeks to carry out its duty to protect the citizens carry out its duty to protect the citizens of the Commonwealth by regulating the of the Commonwealth by regulating the conduct of its licensees. It is the conduct of its licensees. It is the interests of many rather than the interests of many rather than the interests of the few which impels the interests of the few which impels the Board.”Board.”

Miller v. CommonwealthMiller v. CommonwealthContinuedContinued

The court upheld the suspensions of licenses The court upheld the suspensions of licenses of the 3 nonowners but reversed the of the 3 nonowners but reversed the suspension of Dr. Miller’s license because it suspension of Dr. Miller’s license because it found that there was insufficient evidence to found that there was insufficient evidence to show that he knew of the fraudulent claims show that he knew of the fraudulent claims and none of the claims in question had been and none of the claims in question had been signed via Dr. Miller’s signature stamp. signed via Dr. Miller’s signature stamp. Further, because the other surgeons were Further, because the other surgeons were independent contractors and not employees, independent contractors and not employees, he could not be held responsible for their he could not be held responsible for their actions under the legal doctrine of respondeat actions under the legal doctrine of respondeat superior, which would otherwise make the superior, which would otherwise make the master (employer) responsible for the master (employer) responsible for the wrongdoings of his servants. wrongdoings of his servants.

Lessons from Lessons from Miller v. CommonwealthMiller v. Commonwealth

Don’t “up code”- it is fraudDon’t “up code”- it is fraud It doesn’t matter if the patients want you to or that It doesn’t matter if the patients want you to or that

they get benefit from what you dothey get benefit from what you do Don’t try and blame the hired help- you are Don’t try and blame the hired help- you are

ultimately responsible, especially where you sign a ultimately responsible, especially where you sign a contract so statingcontract so stating

You must abide by all the terms of contracts that You must abide by all the terms of contracts that you sign with insurance companies- know what is you sign with insurance companies- know what is in those contracts!in those contracts!

Courts are very deferential to administrative Courts are very deferential to administrative agencies such as Boards of Dentistry provided that agencies such as Boards of Dentistry provided that they have followed their own procedures. For they have followed their own procedures. For example, Rules of Evidence are relaxed in terms of example, Rules of Evidence are relaxed in terms of what is admissible and what is not in agency what is admissible and what is not in agency hearings. hearings.

Lessons from Lessons from Miller v. Commonwealth (con’t)Miller v. Commonwealth (con’t)

Insurance companies may elect from Insurance companies may elect from among multiple possible remedies including among multiple possible remedies including filing complaints with the licensing board filing complaints with the licensing board (administrative law), civil suits for refund of (administrative law), civil suits for refund of money obtained under false pretense (civil money obtained under false pretense (civil law), or, if the magnitude is sufficient, law), or, if the magnitude is sufficient, pursing criminal charges for fraud (criminal pursing criminal charges for fraud (criminal law) as a punishment and to put the dentist law) as a punishment and to put the dentist out of business!out of business!

Penalties for fraud can be suspension or Penalties for fraud can be suspension or loss of license, fines, imprisonmentloss of license, fines, imprisonment

Dentist entered an Dentist entered an Alford Alford plea and plea and was convicted of Medicaid Fraudwas convicted of Medicaid Fraud

KBD placed his license on KBD placed his license on probationary status until he paid probationary status until he paid

the restitution ordered by the the restitution ordered by the courtcourt

Caudill vs. Kentucky Board Caudill vs. Kentucky Board of Dentistryof Dentistry

2006 WL357879 (Ky. App.)2006 WL357879 (Ky. App.)

Caudill vs. KBD Caudill vs. KBD 20062006

Court held that: 1) the crime was one Court held that: 1) the crime was one of moral turpitude 2) KDB has of moral turpitude 2) KDB has discretionarydiscretionary authority to discipline authority to discipline for this; 3) for this; 3) Alford Alford conviction is a conviction is a conviction and 4) It doesn’t matter if conviction and 4) It doesn’t matter if D didn’t know the plea would subject D didn’t know the plea would subject him to KDB disciplinary actionhim to KDB disciplinary action

Adames vs. VelasquezAdames vs. VelasquezNY (2008)NY (2008)

D were a laboratory technician working in his D were a laboratory technician working in his wife’s dental practice and his wife, the dentistwife’s dental practice and his wife, the dentist

P alleges that D offered to provide discounted P alleges that D offered to provide discounted dental services if P came to the office at night dental services if P came to the office at night and paid in cashand paid in cash

P alleges that he was never told that D was P alleges that he was never told that D was not a dentistnot a dentist

Restorative TX done by husband was Restorative TX done by husband was substandard, caused pain and subsequent substandard, caused pain and subsequent tooth losstooth loss

Adames vs. VelasquezAdames vs. Velasquez

D motion to dismiss deniedD motion to dismiss denied Fraud may be committed by a failure Fraud may be committed by a failure

to speakto speak Wife is potentially liable under Wife is potentially liable under

respondeat superior respondeat superior Receipt of payment not necessary for Receipt of payment not necessary for

fraudfraud

Adames vs. VelasquezAdames vs. Velasquez

Cited a KDB case, unlicensed and well Cited a KDB case, unlicensed and well intentioned charitable dentist trained intentioned charitable dentist trained religious missionaries in “practical religious missionaries in “practical dentistry”- KBD barred the action, the dentistry”- KBD barred the action, the court upheld saying. “Nor can we accept court upheld saying. “Nor can we accept the appellant’s proposition that the the appellant’s proposition that the statutes are only aimed at masqueraders statutes are only aimed at masqueraders and quacks who prey upon the public for and quacks who prey upon the public for compensation.” (compensation.” (Lewis v. Kentucky State Lewis v. Kentucky State Dental ExaminersDental Examiners, 300 S.W.2d 241, 1957), 300 S.W.2d 241, 1957)

Adames vs. VelasquezAdames vs. Velasquez

Employer dentists must ensure that Employer dentists must ensure that employees are properly licensedemployees are properly licensed

How bad can it get?How bad can it get?

Office of the Attorney General Office of the Attorney General State of California State of California

Department of JusticeDepartment of Justice

September 22, 2004September 22, 2004 Attorney General Bill Lockyer files criminal Attorney General Bill Lockyer files criminal

charges; This will become: charges; This will become: State v. TeoState v. Teo Central Valley Dentist and 19 others Central Valley Dentist and 19 others

charged with defrauding the state Medi-charged with defrauding the state Medi-Cal System of $4.5 million by performing Cal System of $4.5 million by performing unnecessary dental work on unsuspecting unnecessary dental work on unsuspecting patientspatients

State v. TeoState v. Teo

Defendant placed adds on missing Defendant placed adds on missing children flyers and offered gifts or children flyers and offered gifts or rebates to Medi-Cal beneficiaries who rebates to Medi-Cal beneficiaries who sought services through clinical networksought services through clinical network

Also charged with workers’ Also charged with workers’ compensation fraud, conspiracy, grand compensation fraud, conspiracy, grand theft, child abuse, elder abuse, assault theft, child abuse, elder abuse, assault and intentional infliction of great bodily and intentional infliction of great bodily injury.injury.

State v. TeoState v. Teo Dentists who participated were given kickbacks of 25% Dentists who participated were given kickbacks of 25%

which provided an incentive to over treatwhich provided an incentive to over treat Dental assistants were permitted to perform duties not Dental assistants were permitted to perform duties not

allowed under state lawallowed under state law False insurance claims were filed on fabricated chartsFalse insurance claims were filed on fabricated charts AG says “these dentists put at risk the health and well AG says “these dentists put at risk the health and well

being of hundreds of children and adults by performing being of hundreds of children and adults by performing slipshod dental services that were unnecessary, ignoring slipshod dental services that were unnecessary, ignoring health problems that needed tending and even skimping on health problems that needed tending and even skimping on appropriate amounts of anesthesia before submitting appropriate amounts of anesthesia before submitting patients to painful procedures.” Children were forcibly patients to painful procedures.” Children were forcibly restrained.restrained.

Investigation was conducted by Bureau of Medi-Cal Fraud Investigation was conducted by Bureau of Medi-Cal Fraud and Elder Abuse and assisted by the Department of Health and Elder Abuse and assisted by the Department of Health ServicesServices

Dead men do tell tales!Dead men do tell tales! In 2004, there were In 2004, there were

approximately 25 cases approximately 25 cases of dental fraud pending of dental fraud pending as a result of the as a result of the forensic identification forensic identification of the remains of those of the remains of those who were killed in the who were killed in the World Trade Center on World Trade Center on September 11, 2001September 11, 2001

This was discovered This was discovered when dental records when dental records provided to help provided to help identify remains were identify remains were examined in examined in conjunction with conjunction with remains. remains.

In the matter of the Bar Admission In the matter of the Bar Admission of Edward Littlejohnof Edward Littlejohn

261 Wis.2d 183 (2003)261 Wis.2d 183 (2003) Don’t expect to become a licensed Don’t expect to become a licensed

attorney in another state if you are attorney in another state if you are suspended from the practice of dentistry suspended from the practice of dentistry for inadequate infection control, fraud, for inadequate infection control, fraud, delivery of unnecessary dental services delivery of unnecessary dental services and practices beyond the scope of your and practices beyond the scope of your dental license! dental license!

It didn’t work for Edward Littlejohn who It didn’t work for Edward Littlejohn who was not able to satisfy a character and was not able to satisfy a character and fitness investigation for the Bar after fitness investigation for the Bar after losing his dental license in Minnesota. losing his dental license in Minnesota.

Healthcare Integrity and Protection Healthcare Integrity and Protection Data Bank (HIPDB)Data Bank (HIPDB)

History:History: The Health Insurance Portability and The Health Insurance Portability and

Accountability Act of 1996 mandated Accountability Act of 1996 mandated creation of HIPDB by the Secretary of the creation of HIPDB by the Secretary of the Department of Health and Human Services Department of Health and Human Services acting through the Office of the Inspector acting through the Office of the Inspector General.General.

The legislation that set up HIPDB is Section The legislation that set up HIPDB is Section 1128E of the Social Security Act1128E of the Social Security Act

Final regulations governing HIPDB are Final regulations governing HIPDB are codified in the Federal Register at codified in the Federal Register at

45 CFR Part 6145 CFR Part 61

Background for HIPDBBackground for HIPDB

Cases like Miller v. Commonwealth Cases like Miller v. Commonwealth and State v. Teo REALLY DO occur and State v. Teo REALLY DO occur casting a pall over all of us in the casting a pall over all of us in the dental professiondental profession

Health care fraud is involved in an Health care fraud is involved in an estimated 3 to 10% of all health care estimated 3 to 10% of all health care expenditures and cost between $30 expenditures and cost between $30 and $100 billion in 1997and $100 billion in 1997

Purposes of HIPDBPurposes of HIPDB To help combat fraud To help combat fraud To improve the quality of health careTo improve the quality of health care Accomplished by maintaining a data base of final Accomplished by maintaining a data base of final

adverse actions taken against health care adverse actions taken against health care practitioners, providers or supplierspractitioners, providers or suppliers

Information from HIPDB should be used in making Information from HIPDB should be used in making decisions regarding affiliation, certification, decisions regarding affiliation, certification, credentialing, contracting, hiring and licensurecredentialing, contracting, hiring and licensure

Prevents persons with bad actions/outcomes from Prevents persons with bad actions/outcomes from moving to a new location and beginning practice moving to a new location and beginning practice without consideration of past acts/outcomeswithout consideration of past acts/outcomes

Intended Use of HIPDBIntended Use of HIPDB

A flagging system that serves to alert A flagging system that serves to alert users of the need for a more users of the need for a more comprehensive review of a comprehensive review of a practitioner’s past actions and practitioner’s past actions and professional credentialsprofessional credentials

Should be used in combination with Should be used in combination with other sources in determining whether other sources in determining whether to employ, affiliate, certify or license to employ, affiliate, certify or license an individualan individual

What gets reported to the HIPDB?What gets reported to the HIPDB?

Adverse action on practitioner licenses or Adverse action on practitioner licenses or certification due to fraudcertification due to fraud

Denial of application for licensure or Denial of application for licensure or license renewallicense renewal

Exclusion from participation in Federal and Exclusion from participation in Federal and State health care programs or cancellation State health care programs or cancellation of a health plan contract due to fraudulent of a health plan contract due to fraudulent or unprofessional behavior or poor quality or unprofessional behavior or poor quality of servicesof services

Criminal convictions related to health care Criminal convictions related to health care deliverydelivery

What gets reported to the HIPDB?What gets reported to the HIPDB?

Civil judgments related to health Civil judgments related to health care fraud but not malpracticecare fraud but not malpractice

Injunctions ordered to stop harmful Injunctions ordered to stop harmful or unprofessional practiceor unprofessional practice

Nolo contendere (no contest) pleas Nolo contendere (no contest) pleas to criminal actions involving fraud in to criminal actions involving fraud in health care practicehealth care practice

Who must report to the HIPDB?Who must report to the HIPDB?

““Eligible entities”Eligible entities” defined as: defined as:

Federal of State Government Federal of State Government AgenciesAgencies

OROR

Health PlansHealth Plans

Who must report to the HIPDB?Who must report to the HIPDB?

Federal or State Government AgenciesFederal or State Government Agencies US Dept. of Justice, e.g. FBI, US Attorneys, DEAUS Dept. of Justice, e.g. FBI, US Attorneys, DEA US Dept. of Health and Human Services, e.g. US Dept. of Health and Human Services, e.g.

FDA, CMS, OIGFDA, CMS, OIG Federal agencies that administer or pay for Federal agencies that administer or pay for

health care, e.g. Depts. of Defense and V.A.health care, e.g. Depts. of Defense and V.A. Federal and State law enforcement, e.g. Federal and State law enforcement, e.g.

county and district attorneys and county police county and district attorneys and county police departmentsdepartments

State Medicaid Fraud Control UnitsState Medicaid Fraud Control Units Federal or state agencies responsible for Federal or state agencies responsible for

licensing or certifying practitionerslicensing or certifying practitioners

Who must report to HIPDB?Who must report to HIPDB?

Health PlansHealth Plans Health insurance policiesHealth insurance policies Contract for service benefit organizationsContract for service benefit organizations Membership agreement with an HMOMembership agreement with an HMO An insurance companyAn insurance company MedicareMedicare MedicaidMedicaid Department of DefenseDepartment of Defense Department of Veterans AffairsDepartment of Veterans Affairs Bureau of Indian AffairsBureau of Indian Affairs

Who must report to HIPDB?Who must report to HIPDB?

For you, the important thing to For you, the important thing to remember is that you as an individual remember is that you as an individual practitioner are not required to report- practitioner are not required to report- if you are involved in a situation that if you are involved in a situation that requires reporting, the Board of requires reporting, the Board of Dentistry or other government agency Dentistry or other government agency or the insurance plan will be the entity or the insurance plan will be the entity required to report.required to report.

When does a report have to be When does a report have to be made to HIPDB?made to HIPDB?

Within 30 calendar days of the date that the adverse Within 30 calendar days of the date that the adverse action was takenaction was taken

Once submitted, a notice of receipt of report is Once submitted, a notice of receipt of report is mailed to the reporting entity and to the subject of mailed to the reporting entity and to the subject of the report, so you should know if your name has the report, so you should know if your name has been entered into the HIPDB. Subjects are also given been entered into the HIPDB. Subjects are also given an opportunity to dispute the factual accuracy of the an opportunity to dispute the factual accuracy of the report or the reporting entity’s eligibility to report, report or the reporting entity’s eligibility to report, but only reporting entities can change reports. but only reporting entities can change reports. Subjects can add a statement to the report of no Subjects can add a statement to the report of no more than 2,000 characters. There is no time frame more than 2,000 characters. There is no time frame that limits when a dispute must be resolved and a that limits when a dispute must be resolved and a dispute may be submitted at any time, not just upon dispute may be submitted at any time, not just upon initial notification.initial notification.

When does a report have to be When does a report have to be made to the HIPDB? Con’tmade to the HIPDB? Con’t

Report subjects may file a Notice of Report subjects may file a Notice of Appeal when there is an appeal of Appeal when there is an appeal of the adverse action pendingthe adverse action pending

Can I find out if I have a file in the Can I find out if I have a file in the HIPDB?HIPDB?

Yes, you can query the HIPDB to see if there Yes, you can query the HIPDB to see if there is any information about you there. There is is any information about you there. There is a fee to do so. a fee to do so.

Some insurance plans and state licensing Some insurance plans and state licensing boards may require that you query and boards may require that you query and provide a copy of the result to them before provide a copy of the result to them before participation in the plan or issuance of a participation in the plan or issuance of a license. There is no law mandating that you license. There is no law mandating that you do so, but you will not get to participate in do so, but you will not get to participate in the plan or get a license if you do not! the plan or get a license if you do not!

Does the law require mandatory Does the law require mandatory query by eligible entities?query by eligible entities?

No and this is different from the No and this is different from the National Practitioner Data Base- this National Practitioner Data Base- this is why you may be required to is why you may be required to provide a copy of a self query provide a copy of a self query because then you pay for the query!because then you pay for the query!

Requirement of ConfidentialityRequirement of Confidentiality

Reports made to HIPDB are Reports made to HIPDB are confidential and those assessing confidential and those assessing them have a duty to protect the them have a duty to protect the confidentiality of the reportsconfidentiality of the reports

Patient names are not kept in the Patient names are not kept in the report of adverse actionsreport of adverse actions

HIPDB cannot be accessed by the HIPDB cannot be accessed by the publicpublic

Is there liability for those who report Is there liability for those who report practitioners to HIPDB?practitioners to HIPDB?

No, there is specific protection No, there is specific protection against liability for mandatory against liability for mandatory reporting UNLESS the report is reporting UNLESS the report is knowingly false/maliciousknowingly false/malicious

National Practitioner Data BankNational Practitioner Data Bank(NPDB)(NPDB)

History:History:

Established through Title IV of Public Established through Title IV of Public Law 99-660 in the Health Care Law 99-660 in the Health Care Quality Improvement Act of 1986Quality Improvement Act of 1986

Purpose of NPDBPurpose of NPDB A flagging system to facilitate a comprehensive A flagging system to facilitate a comprehensive

review of health care practitioners’ professional review of health care practitioners’ professional credentialscredentials

Acts as a clearing house of information relating to Acts as a clearing house of information relating to medical malpractice payments, adverse actions medical malpractice payments, adverse actions taken against the licenses, clinical privileges, taken against the licenses, clinical privileges, professional society memberships of dentists, professional society memberships of dentists, physicians and other licensed health care physicians and other licensed health care practitionerspractitioners

May inhibit movement from one jurisdiction to May inhibit movement from one jurisdiction to another of a practitioner who has significant another of a practitioner who has significant malpractice history or has been deemed malpractice history or has been deemed unprofessionalunprofessional

What gets reported to the NPDB?What gets reported to the NPDB?

Medical malpractice payments, either Medical malpractice payments, either settlements out of court or court awarded settlements out of court or court awarded damages as the result of loss of civil damages as the result of loss of civil litigation. (Report within 30 days)litigation. (Report within 30 days)

Adverse licensure actions such as fines, Adverse licensure actions such as fines, reprimand, probation, suspension, reprimand, probation, suspension, revocation, non renewal, voluntary revocation, non renewal, voluntary surrender while under investigation, or surrender while under investigation, or action taken by the Board of one state in action taken by the Board of one state in response to disciplinary action related to response to disciplinary action related to professional competence by another state. professional competence by another state. (Report within 30 days)(Report within 30 days)

What gets reported to the NPDB?What gets reported to the NPDB?Con’tCon’t

Adverse clinical privileges actions that Adverse clinical privileges actions that affect practice privileges for 30 days or affect practice privileges for 30 days or more. (Report within 15 days)more. (Report within 15 days)

Adverse professional society membership Adverse professional society membership actions based on professional competence actions based on professional competence or professional conduct which affects or or professional conduct which affects or could adversely affect the health or welfare could adversely affect the health or welfare of a patient. (Report within 15 days)of a patient. (Report within 15 days)

Exclusion from Medicare and Medicaid Exclusion from Medicare and Medicaid programsprograms

Who has to report to the NPDB?Who has to report to the NPDB?

Insurance companies paying settlements Insurance companies paying settlements or judgmentsor judgments

Licensing boardsLicensing boards Hospitals or other health care entities Hospitals or other health care entities

that grant privilegesthat grant privileges Professional societiesProfessional societies Peer review organizationsPeer review organizations Private accreditation organizationsPrivate accreditation organizations State health care entity licensing boardsState health care entity licensing boards

Penalties for failure to reportPenalties for failure to report

Insurance companies: $11,000 for each Insurance companies: $11,000 for each payment not reportedpayment not reported

Licensing boards: correct the action or Licensing boards: correct the action or HHS designates another entity for HHS designates another entity for reporting to NPDBreporting to NPDB

Hospitals and other entities & Professional Hospitals and other entities & Professional Societies: Publication of noncompliance in Societies: Publication of noncompliance in Federal Register Federal Register and loss of Title IV and loss of Title IV immunity for professional review activities immunity for professional review activities for 3 yearsfor 3 years

Significance of Loss of Title IV Significance of Loss of Title IV ImmunityImmunity

Title IV immunity permits internal peer Title IV immunity permits internal peer review processes to be held private review processes to be held private and not subject to discovery in and not subject to discovery in litigation.litigation.

The rationale for this is that the The rationale for this is that the intention of peer review is to improve intention of peer review is to improve the quality of care at the institution and the quality of care at the institution and if this information were discoverable, it if this information were discoverable, it would not be freely disclosed and the would not be freely disclosed and the quality of patient care would suffer.quality of patient care would suffer.

Who queries the NPBD?Who queries the NPBD? Licensing boards MAY before issuing new or renewed licenses Licensing boards MAY before issuing new or renewed licenses Hospitals Hospitals MUSTMUST prior to granting privileges to dentists or prior to granting privileges to dentists or

physicians and every two years thereafterphysicians and every two years thereafter Other health care entities MAY query prior to employing or Other health care entities MAY query prior to employing or

signing agreements with providerssigning agreements with providers Professional societies MAY query prior to granting Professional societies MAY query prior to granting

membershipmembership An individual provider MAY query at any time, a fee is An individual provider MAY query at any time, a fee is

requiredrequired Quality improvement organizations under contract with CMSQuality improvement organizations under contract with CMS State Medicaid Fraud Control UnitsState Medicaid Fraud Control Units US Comptroller GeneralUS Comptroller General US Attorney General & other law enforcementUS Attorney General & other law enforcement Researchers for statistical data onlyResearchers for statistical data only Plaintiff's attorney or pro se plaintiffPlaintiff's attorney or pro se plaintiff Insurance providers Insurance providers MAY NOT MAY NOT queryquery The public The public MAY NOT MAY NOT queryquery

Confidentiality and Protection of Confidentiality and Protection of Liability for Reporting to NPDB and Liability for Reporting to NPDB and Notification if a Report Has Been Notification if a Report Has Been

FiledFiled

These are the same as for HIPDBThese are the same as for HIPDB

Other facts of interest about the Other facts of interest about the NPDBNPDB

Students are not reportable as they are always Students are not reportable as they are always functioning under the license of a supervising functioning under the license of a supervising faculty who may be reported for actions which faculty who may be reported for actions which occurred during supervision of a student provideroccurred during supervision of a student provider

For the reporting requirement to be triggered for For the reporting requirement to be triggered for medical malpractice payments, there has to be a medical malpractice payments, there has to be a written complaint demanding money. This can be a written complaint demanding money. This can be a formal law suit or simply a letter. Oral complaints formal law suit or simply a letter. Oral complaints that are resolved by payment need not be reported.that are resolved by payment need not be reported.

If the insurance company pays a settlement with If the insurance company pays a settlement with which you disagree, you are still reported to the which you disagree, you are still reported to the NPDB. Check the terms of your malpractice NPDB. Check the terms of your malpractice insurance to be certain that you have the right to insurance to be certain that you have the right to the final determination of settlement if you have the final determination of settlement if you have that choice.that choice.

Other interesting facts about NPDB Other interesting facts about NPDB Con’tCon’t

Individuals are not required to report on Individuals are not required to report on payments in their own behalf as of 1993, as payments in their own behalf as of 1993, as a result of a decision of the District of a result of a decision of the District of Columbia Federal Circuit Court of AppealsColumbia Federal Circuit Court of Appeals

If payments are made by a practitioner If payments are made by a practitioner himself or herself from personal resources, himself or herself from personal resources, there is no reporting requirement. there is no reporting requirement.

Only monetary payments need be reported. Only monetary payments need be reported. Waiver of payment or debt as a settlement Waiver of payment or debt as a settlement device does not require a report.device does not require a report.

There is no lower limit of the payment that There is no lower limit of the payment that triggers the reporting requirement.triggers the reporting requirement.

**Refund offered due to Refund offered due to “Money Back Guarantee”“Money Back Guarantee”**

NeverNever make money back guarantees! Dentistry make money back guarantees! Dentistry is a professional service, not the sale of goods. is a professional service, not the sale of goods. You can stand behind your work without doing You can stand behind your work without doing so this explicitly.so this explicitly.

When you make a guarantee, you have opened When you make a guarantee, you have opened yourself to liability under contract theories in yourself to liability under contract theories in addition to traditional tort theories, which is addition to traditional tort theories, which is where malpractice suits are classifiedwhere malpractice suits are classified

If you do this, you may have to report any If you do this, you may have to report any refunds made under this policy to written refunds made under this policy to written complaints if paid by a third party. But third complaints if paid by a third party. But third parties do not cover contract liability generally.parties do not cover contract liability generally.

Overlap Between HIPDB and Overlap Between HIPDB and NPDBNPDB

Relates to adverse actions against Relates to adverse actions against licenseslicenses

Both were meant to track Both were meant to track practitioners, (and providers and practitioners, (and providers and suppliers in the case of HIPDB) who suppliers in the case of HIPDB) who have run into problems in practicehave run into problems in practice

Both impact geographic mobility of Both impact geographic mobility of providersproviders

HIPDB- think FRAUDHIPDB- think FRAUD NPBD- think MALPRACTICE NPBD- think MALPRACTICE

NPDB Section 1921NPDB Section 1921 New in 2010New in 2010 Expands information collected to include Expands information collected to include

allied health care professionalsallied health care professionals Makes information available to more groupsMakes information available to more groups Expands reporting requirementsExpands reporting requirements Requires all adverse actions, not just those Requires all adverse actions, not just those

related to professional competence or related to professional competence or conductconduct

Data Bank will determine if report is under Data Bank will determine if report is under NPDB or HIPDB of BOTH- more overlapNPDB or HIPDB of BOTH- more overlap

WebsiteWebsite

www.npdb-hipdb.hrsa.govwww.npdb-hipdb.hrsa.gov

Take Home MessagesTake Home Messages Treat your patients well and Treat your patients well and

be loyal to their relationship be loyal to their relationship with youwith you

Do not engage in Do not engage in falsification of claims or falsification of claims or false representations to false representations to patientspatients

Remember that dentistry is Remember that dentistry is a caring health care a caring health care profession bound by a profession bound by a professional oath to put our professional oath to put our patients’ interest above our patients’ interest above our ownown

We are morally, ethically, We are morally, ethically, professionally and legally professionally and legally bound to integrity and good bound to integrity and good treatment in our treatment in our relationships with our relationships with our patients. patients.

If you follow these tenets, If you follow these tenets, the chance that you will be the chance that you will be sued or have your name sued or have your name entered into a data bank entered into a data bank

are low.are low.