Practitioner Fraud in Oral Healthcare

Practical Suggestions for a Counter Fraud Strategy

Liam Lynch BDS MDPHLiam Lynch BDS MDPHOral Health Services Research Centre, University Dental School,

University College Cork, Ireland

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The Challenge: Types of Oral healthcare practitioner fraud

Nonrendered service UpcodingUnbundlingMischaracterisationUnnecessary dental services Routine waiver of co-payments Informal Payments Quackery and sham cures Misuse of modernisation type funds Double-billing Kickbacks

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Suggestions reflect the experience gained in a probity assurance initiative

carried out in Ireland 2006-2007.

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Part One Part One Case StudyCase Study

Republic of IrelandDental Treatment Services Scheme

2006-2007

Dental Treatment Services Scheme 2006Dental Treatment Services Scheme 2006

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The ProblemThe Problem

Concern surrounding inadequate probity assurance in the scheme

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The SolutionThe Solution

The Examining Dentist Initiative 2006/2007

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FindingsFindings

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The key thing we learnt from this initiative

was

““importance of a sound importance of a sound methodological foundation in the methodological foundation in the

design of a counter fraud design of a counter fraud system”system”

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Positive outcomesPositive outcomes

Introduced a counter fraud culturePatients expressed satisfaction with

the scheme and with their dentistQuality of treatment generally

satisfactory

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Part 2Part 2Reflections on the Examining Dentist Reflections on the Examining Dentist

Initiative: Initiative: I offer my opinion both as an I offer my opinion both as an Examining Dentist and as a Contracting Examining Dentist and as a Contracting

Dentist Dentist Strategic issuesOperational issues

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First Five Areas for ConsiderationFirst Five Areas for Consideration

Budget allocationOrganisational positioningThe role of the representative bodyThe number of personnelSemantics

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Budget AllocationBudget Allocation

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To be effectiveTo be effective

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Organisational PositioningOrganisational Positioning

The Examining Dentist Initiative The Examining Dentist Initiative was positioned within the was positioned within the payment agency for the payment agency for the SchemeScheme

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To be effective:To be effective:The counter fraud unit should The counter fraud unit should not be positioned, as a not be positioned, as a subordinate, within a payment subordinate, within a payment agency or divisionagency or division

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Organisational PositioningOrganisational Positioning

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RepresentationRepresentation

The role of the professional representative body was central

for a counter fraud initiative to be effectivebe effectivethe role must be appropriate

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Representation and scaleRepresentation and scaleToo many people from too many

divisions involved in planning and management

Keep counter fraud lean and mean

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Semantics: linguistic gymnasticsSemantics: linguistic gymnastics

Terms Employed in place of ‘Fraud’

inappropriate paymentsirregular paymentssupplier-induced demandsupplier-reduced demandunofficial activityimproper paymentsscammingplaying the systembrown envelope payments

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Next Six Areas for ConsiderationThe use of the patient/client as a counter fraud officer Redress Provider identity systems Prior approval of treatments a panacea?The Human Touch in claims processingClinical Peer Review

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The use of the patient/client as a counter fraud officer

we can harness patientswe can harness patients

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Redress

A practitioner merely refunding the loss involved in a detected case is not a sufficient deterrent and alone must not permit the case to be closed

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Provider identity systems

Must be: UniqueRobustNon-recyclable

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Prior approval of treatments: a panacea?

Proposed as a solution to Upcoding, Unbundling, Mischaracterisation, Unnecessary

dental services and Quackery

Dental advisor must exercise Care

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The Human Touch in claims processing…

Is indispensable

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Clinical Peer Review

Ticks most of the Boxes

Good Afternoon and Thank You