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“How to Make More Money and Stay Out of Jail!”With special guest, Dr. Paul Bornstein

Welcome to the Madow Brothers audio series with Rich and Dave Madow.

Richard Madow: Hi, I’m Dr. Richard Madow, and our guest today is Dr. Paul Bornstein. How are you doing today, Dr. Paul?

Paul Bornstein: I’m doing just fine, Rich. I can call you Rich, I hope.

Richard Madow: Think that is totally acceptable; that’s probably the nicest thing you can call me.

Paul Bornstein: Yeah, I’m sure, ok. How is everybody?

Richard Madow: Everybody is fantastic. Things are great up here in our part of the world, but they are really great with you. You are some busy guy. We last had you on the audio series many years ago, and I can remember your interview was hugely successful, and we’re glad to have you back again. Boy, have you been busy, and I’ll give you a chance to explain why some of our longer-term subscribers are familiar with you and they remember that interview. But most people probably have not heard it, so you are a former practicing dentist. You got involved in insurance consulting, and I’ll just let you tell the rest of the story. How did you wind up doing what you do, and what is it that you do, exactly?

Paul Bornstein: The long and short story is back in 1993 I practiced for 30

years and taught at Tufts and Harvard part-time all of those years, and ended up having to go on disability from a ripped-up shoulder and paresthesia. For two of the three I had a lifetime policy that allowed you to do anything else, and they don’t even sell these anymore. And I fell into a

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situation; I became the dental chief of a company called Sun Life of Canada Dental Insurance for five and a half years, doing all their claims, overseeing their appeals, and every time a contract is written when the new codes change, somebody has to sit with a computer nerd and make it all happen. I did all of that stuff plus I developed what is called an SIU, which is a special investigative unit for fraud, and when they sold out in 1999, and I said to my wife for the fourth time, I guess I’m retired, and then someone said, can you do a little bit of speaking on the subject, and that has been 16 years, 1,500 lectures. Companies, and then the big ones like Yankee and Greater New York, and then I’ll make a tape for someone like Rich Madow, and that was the highlight of my career. That being said, the driving force behind this business now, and frankly, I have been busier than ever, is that the amount of fraud and the Affordable Care Act and the scrutiny of docs being hit with incredible fines, and everyone is nervous, plus the economy has gone a bit south, as we all know, over the last five, six, seven years. Basically, what I’m all about now, my programs and my in-office consult, is how to make more money and stay out of jail, and that’s who I am. I have been very, very lucky, and people tell me I’ve help them a lot, and basically I have dealt with doctors who have gone to jail and I have dealt with the FBI. In my regular full program I show emails with me back and forth with the FBI, and if we have time during the program, maybe I’ll talk a little bit about that, but that is not the focus of the program now. I’m ready to go when you are.

Richard Madow: Let’s remember. I hope we get to that. Everybody loves a good spy story, and not that many dentists get to work with the FBI, so that’s pretty cool. Before we get started on the meat of the program, just to clarify things, I know you do a lot of speaking, but who actually hires you, other than going to an office and consulting with the dentist or maybe the dentist has got into some trouble? Which side are you on? Does an insurance company hire you? Does the government hire you? And how does it work?

Paul Bornstein: It’s 100% the doctors and dental associations or a company called Cross Country Education, which is a national lecture company and now all over the country, teaching dentists and staff how to bill correctly and stay out of jail; that’s what I do. I work 100% for docs, staff, and frankly, there are several cases that I’m involved with now

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to oversee practices, whether they are going to lose their license and I have to basically hold their hand, look, audit their records, find out what they have done wrong this year, talk to them, write a report to over three to four years, and they keep their license, and this is how they do it, with someone like me to oversee behind the scene a little bit, and that’s all I do. I’m 100% working for the docs.

Richard Madow: You’re on the right side and that is fantastic. I love the title of your talk and of our interview today, “How to make more money and stay out of jail,” so I know we’re going to be talking about some specific codes. I think some people could figure out what it is that makes you some more money, but what are some of the things that would put someone in jail?

Paul Bornstein: In jail? Obviously, incorrectly billing Medicaid more than anything else, dental insurance fraud, and I could spend two hours on a tape giving you a course on... one of the big things to focus on is not one of the things that you and I have talked about, is discounts. Every dentist in the country give persons discounts. 10% for cash, 5% for purple shirts on Tuesdays, whatever reason. 3% for odd numbers in my street, my mother, my father, my uncle, my sister, my brother, my staff and they have insurance and never put it on the claim form. That’s a federal crime.

Richard Madow: We’re off on a tangent already and we haven’t even gotten to the first thing on our outline.

Paul Bornstein: Oh no, you wouldn’t, you wouldn’t do this for an hour.

Richard Madow: But I’m glad you brought it up cause, honestly, it’s a question I hear all the time, and that is our office has a policy; we give 8% discount if you pay by cash or check before treatment begins. Is it technically legal to do that only on the copay?

Paul Bornstein: Okay, you ready? This is going to take a while.

Richard Madow: Give your most condensed version.

Paul Bornstein: That is pretty tough, I’ll try to spit out the legalities and this is very hard for the dentist to swallow when they listen to this tape. One, if you’re going to give a discount, whether you

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participate or not, the federal law and all state laws say the same thing, and the ADA code of ethics, you must inform the third party that you’ve done it. For an example, in the example that you just gave, let’s say the fee is a thousand bucks for a crown and you’re going to give the patient 10% off; it’s now 900, but insurance pays 500 and patient pays 500 given on the patient portion. You can do whatever you want to do, but as long as it is on that claim form that you did it. You must inform the third party, in the remarks section, where we have given the patient 10% off of their copay, whether it is electronic or whether it’s paper claim, which one you’re doing, you must always put your full fee down. So if it’s 1000, it’s 1000, you won’t put the 900 down if you’re a participating provider, the requirement of your contract, doc, you never read, cause docs never read what they sign, they have no idea what they did to themselves, and that being said, the full fee down in remarks section, and say, this is what I did; why you did it, nobody cares. Your obligation, legal obligation, is to inform the third party that you have done it. Secondarily, how about if I do it for non-insurance only? That is a federal crime. That is discrimination; you cannot do that. Thirdly, and to really muck up the works as they say, under federal guidelines, through the Affordable Care Act, and this is the FBI telling me this, two heads of two different states, in the last five months, Arizona and New Mexico, one of whom I have actually lectured with and the other one actually lectured to us; the head of the fraud desk of the FBI for healthcare fraud. If the federal government in any way participates in payment of the patient premium, you are not allowed to give a discount, period, unless the federal property guidelines come into play and you made a good faith attempt to collect it. The problem is under the Affordable Care Act, almost five million people now, part of your premium is in some way supported through tax credits; therefore, you would have to be privy to your patients’ IRS history and tax forms, which you’re not ever going to be; therefore, over the last six months, I have changed my lectures and I tell people you’re out of your mind if you give anybody a discount for anything ever because you can’t know if the government is supporting in some way. That’s my very quick story, Rich.

Richard Madow: I think it is good practice management advice to do sometimes, but interestingly, I’m a big fan of giving a discount for cash, check, and credit card as you pay...

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Paul Bornstein: And if you do it, one of the things that I recommended for people now, and this is very current stuff I have been doing in my lectures, okay, if you’re going to do it, understand that you can’t discriminate against insurance and non-insurance, so my best advice is don’t even offer it. Let them ask you, and that’s fine, and everybody should have an office manual, and in the office manual it should say, “The rules of the office are we do not discriminate between insurance and non-insurance, and if the patient asks, then we will give it, and we would disclose it on the claim form.” What we have done with all of that is called CYA. Cover your butt, and you’ve documented the fact that you have done it completely legally that way.

Richard Madow: I think CYB is cover your butt; CYA is cover your ass. Maybe from my vantage point, which is always increase production, manage your practice better, and we can say raise your fees 10% and then give everyone a 10% discount, and you’re no worse off.

Paul Bornstein: I think I know, sort of how you operate, what you try to point to, you’re very high end, increase your fees and all of that. I often joke in my lectures, I have visited the dark side and I am the dark side, and I want people to follow the rules and not get in trouble. I hate to see some of the stuff I’ve seen. I just completed a case. It’s very famous, and you can look it up; it’s the $17 million case in Austin, Texas. Board-certified pedodontist office. The Office of Inspector General, they wanted $17 million for Medicaid fraud, and I’ve acted as one of the defense behind the scenes, in the negotiations with the government. I’m proud to say, and the lawyer called me up in August, and I had helped them build a case, the case never even went to court or deposition. From 17 million, they settled it for $39,000, and they tell me I was a part of it. The government is stupid, but that’s another story. I teach people, and that is part of this tape today, I teach you what you have to do legally, correctly; you don’t like it, but I’ll teach you how to make more money too, and the biggest reason dentists lose money in this country, they’re losing a fortune, failure to bill for what they do.

Richard Madow: I guess we better get down to discussing some exact codes. That was a great teaser. As you said, we’ve got to fly, and I know you got a lot of stuff here; we already went

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off on two or three great tangents, which I know are very helpful. People probably got their hour’s worth already from this interview.

Paul Bornstein: They got to go to CVS to get their diapers because the truth... Yeah, these are the lines I use in my lectures, anyway, that being said, and I tell everybody in my audience, 110%, everyone of you is committing a fraud or a felony every day, probably on an hourly basis, you just don’t know, and it’s never a crime until you get caught.

Richard Madow: I have already committed several felonies today, possibly one misdemeanor. Let’s talk about procedures that are flagged or watched all the time. We need to know that some procedure codes raise the red flags and others don’t. I admit it right now, you have given me a list and I don’t really know this stuff. I admit it because I think it would be good if I looked at the list and throw a code out at you and you told us what you know about it, so you start with a pretty simple thing, code for periapical X-ray films. The 0220 and the 0230. What is the problem there?

Paul Bornstein: The problem there is the overuse of a code. I’ll go through a couple different scenarios and I guarantee some of the docs sitting in the audience, or to listening to the tape, excuse me, do this stuff. One of which is they’ll take 4 bitewings and 2PAs routinely on a recall visit. That does not follow federal guidelines; there is an FDA guideline for X-rays, and I’m sure most of the dentists say they didn’t know there were guidelines for X-rays, and obviously they don’t have a slide for it, but they can actually find that on www.ada.org. The FDA guidelines for X-rays, and then they can see how they take X-rays inappropriately, and it all comes under one thing – what was the medical necessity? Every contractor in this country, every Medicaid contract, every Medicaid law, every insurance rule, was it necessary, was the work necessary? Is a bitewing necessary every six months? Are they necessary every year? Why are some companies now allowing bitewings once a year and some every two years, some every three years, why? You got this kid with a perfect mouth, is 22 years old, flosses like crazy, brushes like crazy, he was born in Texas and he lived in fluoride, 4 ppm in water. This kid is a low risk patient. You know what the FDA guidelines states? You know, a bitewing should be taken, probably don’t, every two to three years. What we look for, insurance companies,

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and you’re being tracked by the most sophisticated computer systems you can ever dream of, we’ll talk about that also. The fact of the matter is, what’s the statistics in your zip code? Are you two standard deviations from the norm? Are you at the 97th percentile, meaning you take a whole lot more than the guy next door in the same zip code? Why? Tell us, explain it to us. You are being flagged, and the biggest flag with bitewings, excuse me, PAs, which is 0220 and the 0230, which are regular PA and the supplemental film. Here is how one code leads into another. The recall visit, 0120, which is the recall exam by the doc, the evaluation. When they see, as an example, I have a letter in my lecture for this, somebody sent it to me that attended my lecture. You take three times as many PAs on a recall visit than the average in your area; what the hell are you doing? Now, United Concordia, which is close to your home territory in Pennsylvania, and you are in Maryland, they sent out letters to every dentist in the state. If you take bitewings and you take PAs at the same time, we’re not paying for them, and as your participating provider, we never will unless you can prove why you took them; therefore, we’re going to require a copy of the patient record and examine the record before we pay for the PAs. Why? Wasn’t medically necessary. If you want to use a medical metaphor for the whole thing, go back to when we were younger or certainly our parents’ age, every time they went to the doctor they got a chest X-ray; nobody does that anymore. It’s the radiation and the cost, and that’s just the way the world works. They’ll know, every doc, what you’re doing, every doc is being tracked on. All 162-182,000 dentists we have in this country are tracked, and there are two companies that do it and sell it to the insurance companies. They know every code you bill, the frequency you bill it, and how much you charge for it, and your zip code, and they do pie charts, and the insurance companies can buy this information, and they do. At $50,000 every six months, and they’ll know which docs to watch in their company.

Richard Madow: It’s just amazing that someone is telling you, you shouldn’t be taking a PA when they have no idea what’s going on in your office or what your level of care is...

Paul Bornstein: I didn’t say you shouldn’t take a PA. No, I’ll be your patient and I’m sitting in your chair. You practiced dentistry occasionally, once in your life, more than that, I know, but

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I’m sitting in the recall chair and the hygienist and you’re looking at me, and you know these rules, uh-oh, I better not take these... Hey, Dr. Rich, I got this bump over this tooth over here. You say to the hygienist, hey, take an X-ray. Not a problem, and it’s documented why you took the film; it was a medical necessity for it.

Richard Madow: Document it all, baby.

Paul Bornstein: You know what, the court cases I’ve been in, and the stuff I’ve seen, you can never put too much in a record, never, and I tell everybody now, go buy 20 machines, photograph, photograph, before, during, after the prep, leave it in your computer, nothing, but it helps, it’s proof of what you’ve done and the necessity of why you did it.

Richard Madow: Sounds good. Hey, let’s move on to the next code. I got to say, this one surprised me. The 2391 single-surface posterior composite. Simple restoration, everybody, so many people need that; it’s not expensive. What’s the problem?

Paul Bornstein: The biggest problem with that one is that, and I’m sure everybody will say to me that’s a general dentist, the patient comes in, the guy is 50 years old, has occlusal decay on number 19. The doc says, Paul, you need a filling, go ahead, doc, I trust you. Cleans out the decay, didn’t go into dentin but cleaned out the decay, put it in nice flowable composite or any kind of composite, it looks gorgeous, wonderful, thank you very much. And guess what? You didn’t go into dentin. The code says, you had to have gone into dentin. People don’t understand the way the codes are written, you must conform to the literal definition of the code, and you’re billing under the HIPAA law, and there are three portions to the HIPAA. You and I have a history with HIPAA going way back. And that being said, third part of HIPAA is a transaction portion of a law which states, and I’m paraphrasing, using the ADA words, you must bill for what you did at the time you did it with the literal definition of a code. If you didn’t go into dentin, then you flat out didn’t do it. You did either a sealant or the new PR, preventive resin restoration, 1352; sealant is 1351. However, problem is, once you’re over 14, 15, 16, depends on the contract, where are you? Insurance companies don’t pay for it, and that comes under the heading of too bad; you better inform your patients,

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because if you didn’t go into dentin, and statistically, you do way more than everybody else, in comes big brother, prove to us that you went into dentin. Did your records say you went into dentin? Do you show photographs? And I have people that got out of trouble because they’re so anal, they took photographs of the patient they prepped before they put the filling in to show the yellow of the dentin with a little brown stain, and guess what? We want all our money back, and now we have to go back five years, by the way, and we want our money back with a bunch of other stuff. And/or maybe they want to put you in jail. Medicaid is good for that one.

Richard Madow: I got to say, to quote the late Groucho Marx, “That’s the most ridiculous thing I’ve ever heard.”

Paul Bornstein: All I can do is be the messenger.

Richard Madow: How do they know if you went into dentin are not? That’s ridiculous!

Paul Bornstein: I set you up for that question. How do they know? Give me 100 X-rays preop and I want to see if there was decay there, and I know you’re going to tell me, you did go to dental school; how old are you? You can’t even see the dentin or occlusal decay on an X-ray; that’s true. Take the hundred, first 70 we won’t even look at them, 30 we should be able to see something. In other words, it’s all statistics, Rich. Now we look at your record, now we maybe want to see postop films. I’m not telling you “we” because I represent the doc; but this is what the companies and Medicaid does.

Richard Madow: I just shudder to think that now, every dentist listening to this interview is gonna be leaning a little bit more on their bur to make sure they nick a tiny piece of dentin.

Paul Bornstein: I know that’s an old joke and I talk about that in my lectures too, and I say you’re the kind of guy that you’re going to lean a little heavier, you better have records that say you were in dentin, you better have all kinds of stuff. The problem with all of this is, if the guy or the female dentist, actually 60% of graduates are female now, if they lean a little heavier, you know what? The insurance company’s suspicion is up. What else are we going to look at? Trust me; they’ll find something.

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Richard Madow: Too much. Let’s move on to the next code, which I have to say, this one I’m not so surprised about but maybe you can explain why this one is been flagged a lot, and that is the 2335, the good old incisal edge composite or composite as they would say up north.

Paul Bornstein: It’s cosmetic. Somebody comes in and they have diastemas, no decay, nothing broken, but they want to get rid of their diastemas, and you’re real good with composites; you don’t even go on the facial, and you build it out with a 2335, and you get paid, and hell, they pay, so what’s the problem? The problem is those codes are what we call auto adjudicated. Auto adjudicated means nobody ever looked at the X-ray, it goes right through the process electronically, and a check comes out the other end. Now every contract, every state law, every state law says the same thing. There has to be a medical necessity to be doing it. This is cosmetic in nature, and therefore, bottom line, you can’t do it. And I’ll tell you some very interesting things. Actually, the dental director of Delta of Illinois, they’re investigating right now, and some doc’s up against some big fines, an orthodontist in Illinois. He was billing mesial and distal composites 22 through 27. Why? I can’t get paid for my wire, my ortho wire. I’ll bill it as composites; who is going to be wiser? Same thing for perio splints. They don’t get paid by contract. Doc says, I’ll do it this way. Trust me, companies watch for this stuff.

Richard Madow: I was going to ask a similar question. Are you better off billing for a three-surface or four-surface composite rather than incisal edge? I guess if you do too many of those, you get flagged too.

Paul Bornstein: You’re not supposed to bill for any of them. This is a cosmetic procedure. I don’t care if it’s one surface, if it is not medically necessary, there is no decay, or wasn’t broken, the bottom line is the patient pays the bill. I like to call it the four C’s, that’s what they use: cash, check, charge, or CareCredit.

Richard Madow: I’m so glad you mentioned CareCredit; we love CareCredit.

Paul Bornstein: Actually, I will be blunt about it. They’ve been supporters of my lectures financially for 12 years now.

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Richard Madow: You’re so into full disclosure.

Paul Bornstein: I don’t care. I tell people, you have to when you lecture, by the way. Because if they’re going to get credits, are you getting paid by anybody that we talk about? It’s part of the deal. I’m from the Academy of General Dentistry and the ADA.

Richard Madow: I know, and people should know. Move on to another one, and this one has been controversial for years, and I think it’s a judgment call, and in my opinion, just about, I shouldn’t say just about every, but so many crown preps need core buildups, the 2950, and I think that a sloppier dentist might not put it in and just hope that the metal or the porcelain or whatever fills the gaps. I think it’s better dentistry to do the core in most cases. Why is this a problem?

Paul Bornstein: Again, you deal with statistics. The national average for crown buildups for crowns is about 35%. I show these letters in my lecture. MetLife sends out letters threatening docs with all kinds of stuff, and they actually quote the averages in these letters. Here’s the deal. In Baltimore, what’s an average fee for a crown in Baltimore? $1,200-$1,500?

Richard Madow: It depends on the part of Baltimore. I was gonna say $1,200.

Paul Bornstein: All right. Make it $1,200. All right, patient comes into your practice. They have an old MOD amalgam or composite, and you say, you know what, Paul, I’m seeing cracks here, cracks there, cracks everywhere; you really need a crown. Fine, Dr. Rich, I trust you, whatever it is, how much is my insurance going to pay? Your insurance is going to pay 600 and you will have to pay 600, I’m a participating provider. Terrific, go for it, doc. You prep the tooth and you clean out the amalgam or composite. Now, the buccal and lingual walls are still standing there, and there is still some dentin supporting the wall, and you have been doing dentistry for 30 years; how long is that going to take you? Couple of minutes, max. And a little bit of decay, no decay, cause you’re not going to put your beautiful $1,200 the crown on a swamp; that’s the usual mantra the docs say. And I’m good with that, not a problem, and now you put in some core paste, hit it with the light, and you prep the tooth.

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Was that a crown buildup? I guarantee, listening to what you said to me, that would be a crown prep. The answer is, of course, it’s not. I mean, not a crown prep, excuse me, a crown buildup. What is it? It’s actually a filler, in other words, if in fact you’re filling it to have idealized the prep, then, in fact, there’s a new code for it now; it’s 2949, meaning, you’re using it, putting the material in to idealize your prep. The problem, now you’re billing correctly because that’s what you did, problem is, no one is going to reimburse you for that. Insurance companies won’t pay for that. It’s not part of their contract, so now the patient is going to have to pay for it. As a matter of fact, very interestingly, about a few months ago, I happened to have a couple cocktails with the dental director of United Concordia. They said they are so fed up with this code, 2950, and arguing with doctors; they are very seriously considering new contracts dropping the code and never paying for it, and increasing what they pay for the crowns a bit; therefore, nobody will argue anymore. Either it is what it is or you can do what you want.

Richard Madow: That’s actually a great policy. I wish they would do that.

Paul Bornstein: I think it is, to tell you the truth.

Richard Madow: I remember I used to hear in the old days that they would pay for the core if you did it on a separate day as the crown prep, which I thought was total bullshit.

Paul Bornstein: That’s another old story. MetLife started that. And the bottom line, the way around that problem is, they want to know that you’re actually doing a crown; the way around that historically is to get a preestimate for a crown; then they know a crown was coming. That’s the simple way to do that.

Richard Madow: So what’s your bottom-line lesson about billing for the core buildup?

Paul Bornstein: So what is a crown buildup is what you’re asking me. The answer is if two cusps are missing... truthfully, to be blunt about the whole thing, it’s a very difficult problem. In some states, the insurance companies, and usually the leader of the pack is Delta, in some states they pay; no questions. In some states they give you a real hard time, and it just depends on how they sell their policies. And if I had all of

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the 400 dental consultants in this country sitting in the room with us right now, and you walked around and you said to them, what’s a crown buildup, and by the way, it’s not called a crown buildup anymore; it’s called a core buildup, what is a core buildup in your eyes? You’re gonna get 400 different answers. I tell people now to take a photograph before you do it, after you’ve cleaned everything up, before you do anything else, the old amalgam or composite, and then after you put the core material in it and the final prep. Truthfully, if you’re within the statistical norm, I would say around 50%, most of the time, nobody’s going to bother you very much, but you always want to have the back up and the documentation, and photographs are part of the documentation.

Richard Madow: I love the photograph too, great call. I got to say, so far it’s got to be the most interesting stuff I’ve ever heard about dental insurance and coding, and that’s why I love the title, “How to make more money and stay out of jail.” If it was called, like, “Insurance coding update,” I think people would think I’m going to play this when I’ve trouble going to sleep one night, but this is really interesting, but not only interesting but super important stuff, so thanks, man, thanks so far.

Paul Bornstein: I’m just getting warmed up.

Richard Madow: Ok, let’s go to another code now, again, one of my favorites, and something I think so many patients need. I think it’s underdiagnosed, underperformed, and now you’re going to tell me you might get in trouble for doing it. I don’t know why. It’s the old 4341 scaling and root planing by quadrant.

Paul Bornstein: I can spend about an hour on this one, but I don’t even know how much time we have left, to be honest with you. Let’s discuss the whole issue. A patient comes into your practice, Rich, and I’m making you the dentist, okay. And your hygienist does a full six-point probing, and no doubt in your mind, she looks you in the eye and says, Dr. Rich, these are valid measurements. I’m comfortable with it, I wasn’t bouncing off walls of calculus, the patient didn’t jump up and punch me in the nose. I’m good with it, fine. I’m telling you right now, the greater preponderance, and by the way, the pocket depths are pretty much universal, 5, 5+, and it’s a full complement of teeth other than the

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wizzies. Ninety-plus percent of the dentists in this country, we’re looking at a four quad scaling and root planing case, 4341. We might do two quads at a time. The American Academy of Perio, just as a sideline, has in their guidelines from the World Congress in 2000, 45 minutes to one hour per quadrant with the use of local anesthesia; that’s the standard of care of the American Academy of Perio. Okay, so you need four quadrants. Is this patient a perio patient? I don’t know yet if this is a perio patient. You need something else. What do I need? I need an FMX. I look at the FMX and I see a minimal bone loss, maybe a half a millimeter in a few places. This patient is not a scaling root planing; it’s fraud to bill it. I know it gets paid by a lot of companies, and I’ll explain why in a moment. But why isn’t it a scaling root planing? Because it states in the code 4341 or 4342, which we’ll talk about in a little while, which is a partial quad of one to three teeth definition of the same. You have had, and I’m paraphrasing, you have to scale the root of the tooth, or instrument the root of the tooth, and it can’t be done unless bone is missing; therefore, if you don’t have at least one and a half to two milliliters of bone, and a lot of the contracts actually say that now, we’re not paying because you did not instrument root. By definition, therefore, it is not scaling and root planing. And I can’t tell you how many cases I’ve seen where the X-rays come in and there’s no bone loss and they want to know how come they can’t get paid, the patient had a 4+, 5, and they’re bleeding. Who cares? That’s not what the definition says. If you can’t instrument the root of the tooth, you can’t call it a scaling and root planing.

Richard Madow: So what you do with that patient that has 5’s and there is blood everywhere?

Paul Bornstein: It depends on the situation. If the doc can’t get, or the hygienist can’t get what they think is a valid probing. In other words, I’m really not sure that these are the right measurements. Not a problem. One thing, this patient will be is a gross debridement, 4355. Now, that leads into another question. Okay, can I use an exam code? You can’t do an 0150 or an 0180, which we’ll be talking about which are the comprehensive exams, because to do a comprehensive exam you must have a perio chart. While that being said, well, hell, who is going to do a gross debridement without examining the patient first and an

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hour’s worth of stuff flying all over the place, so that would be a 0140, which there’s another reason to use that code; it’s a limited oral evaluation, so that would be a 0140, 4355. Patient comes back ten days, two weeks, whatever the doc or the hygienist decides, and then they do a full comprehensive exam, and then you decide is this patient a scaling and root planing? And what the companies are looking for is 1.5 to 2 mm of bone loss and a total of 5 mm of lost attachment. It’s basically a combination of pocket depth and bone loss; that patient, they are entitled to a scaling and root planing.

Richard Madow: Wow. It’s the age-old problem. It’s just creepy to think that decisions are being made based on gross generalities when no one has ever even seen this patient and determined what they need.

Paul Bornstein: It doesn’t matter. That’s just what I’m trying to get through to you just like with every other dentist. I’m serious. The insurance companies, and the money is not even coming out of the insurance company’s pocketbook. Almost all plans today, TPA, third-party administrators, administrative assistants only, they are only managing claims for only 3, 4, 5 bucks a claim. The money comes out of the employer’s checkbook, and the employer makes all these decisions. Every single claim form is a legal document. When you put a code on that claim form, you swear you did it. You swear you have followed and done exactly what the literal definition of the ADA code is. They own the codes, so it’s all law. I swear I did this. Now go look at the code book and the record will see that I did what the code said.

Richard Madow: It sounds like a great portion of I’m doing this correctly; I’m doing what you’re preaching, doing it correctly, is really knowing the true definition of every code, which I think few of us do.

Paul Bornstein: Of course, and I recommend and I don’t know if you have ever read it or dealt with Charles Blair.

Richard Madow: Sure, Charles Blair is a great guy.

Paul Bornstein: He’s a great guy. Well, his book, I sell it in every lecture; it’s the greatest thing he ever did for anybody and he updates it every single year, the full definition of every single code. You don’t even have to buy the ADA codebook

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because he is licensed to, and how insurance companies look at it, what you should look at. It’s the best thing since Swiss cheese or sliced cheese ever for dentists.

Richard Madow: I just can’t imagine anyone ever reading it; that’s the problem.

Paul Bornstein: Well, you know what? Whose butt is it in the end? You haven’t had the experience that I had. So help me God, people call me on the phone, male and female dentists, crying hysterically on the phone.

Richard Madow: Probably from prison. You get one call from your prison cell, I’m going to call Paul Bornstein, and I just can’t imagine this scenario, like, you went into the prison and the cellmates are “So what are you in for? I’m here for murder. What are you here for?” “Well, I took a periapical film, 0230, and...”

Paul Bornstein: It’s not quite that simple, as you well know. The truth of the matter is documentation, documentation, and then when you get done, document again.

Richard Madow: Document your documentation. So those were a bunch of codes that will teach you how to stay out of jail. Don’t overuse these codes. They are frequently overused, and if you’re going to use them, you better know exactly what they mean. Let’s talk about maybe the opposite; you got a list of codes that you think aren’t billed enough, and we should be billing them, so this is a total 180 here, and a few of these you already mentioned, I think you mentioned this one already, the 0180, the comprehensive perio exam.

Paul Bornstein: This is a code that is grossly underbilled. So let me discuss it for a moment. An 0180 is a comprehensive periodontal exam. What an 0180 is, it’s exactly the same thing. It’s a new patient exam and it should be used... And the American Academy of Perio and the ADA say at least 50% of all adults have some form of periodontal disease. They could be a smoker, they could have diabetes, they could be taking Coumadin. It could be anything, and they have to have a more comprehensive exam. Bottom line, 50% of your adults over the age of 30, and I’ll give you the age of 30, the reason why, in a second. They should be billing as an 0180. Most companies pay it, and they pay it at a higher rate than an 0150. Some of them will downgrade it

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and call it an 0150, so they do, and some patients will have to pay a few bucks more, $20 or $30 more. I’m telling you, figure out how many adults you have in your practice, new patients, and you bill that, and I believe personally, I’ve done a lot of in-office consults, dentistry is a meat and potatoes game. If you do 500 of this and 300 of that and you get two bucks more for this and five bucks more for that, at the end of the day, it adds up to a lot of money, and 0180, the key is with that code, that it has to be documented, and the difference between the 0180 and the 0150, which is a comprehensive exam most people are used to, but that particular code for a new patient, 0180, says you must do a perio chart and an 0150 says you may do a perio chart. However, most people do them anyway. That’s okay. That’s the biggest difference. Also, with 0180, most people don’t realize the perio maintenance procedure, the 4910, a number of companies, I can use Met’s PD plan, a number of Deltas, docs or hygienists will do a full-bore perio chart once a year because people of perio maintenance, plus do a complete exam again. Don’t bill it as a recall, bill it as a 0120, and a lot of companies will pay much higher fee rate than 0120. You stop to think about that. All of these things add up, and I’m sure I’ll have a chance to tell you a couple more before the tape is over. That being said, please do yourself a big favor and use the code, because it absolutely is paid for by lots of companies. I mentioned the age 30, by the way. The dental director of MetLife, his letter, I show lots of letters from him with his signature in my lecture, he told me, all my lectures last year I told everybody in the audience this, if MetLife receives a claim for a full quadrant of scaling and root planing, 4341, and the patient is under the age of 30, until proven otherwise, they look at that claim as fraudulent.

Richard Madow: Nothing like a gross generalization again. Quick question to you about 0180. Is there a time where we can use that, in the same time period as the 0150? Are they mutually exclusive? How does that work?

Paul Bornstein: They are mutually exclusive with the exception if I came in and you did an 0150 on me, and in the course of treatment planning, you opted to scale and root planning and you approve it and I needed it, and a year later you can bill it as an 0180 upon the exam.

Richard Madow: Sounds good.

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Paul Bornstein: At a higher rate, remember, at a higher rate.

Richard Madow: I was going to say something that would open up a whole can of worms that we can’t open right now. Let’s get to the next code. I got to say, I don’t have favorite children; I love my children equally. I think my favorite code of all time and that is the 9110 palliative treatment. Tell us about that one.

Paul Bornstein: I don’t know if you remember but Dr. Blair has either five or seven pages of that one code. I’ll try to give you some examples. First of all, the key word is pain. P-A-I-N. Any time a patient is in pain, you can bill that code. I’m going to give you a bunch of examples and scenarios. Patient calls up and says, I have a terrible toothache, Rich. Can you see me? Well, sure, come on in. I come in, I need an endo and it’s tooth number 29. You prep the tooth or you take an X-ray, you give me a local anesthesia, you put the drill on the tooth, and my head hits the ceiling. Whoa, I can’t handle it. An intrabony injection, you get down and dirty, it takes you 45 minutes or an hour. That’s enough for today; you can come back next week and I’ll finish the endo. Now you have two choices of code there. 3221, which is a pulpal debridement, or the 9110. Why? You got me out of pain. I can show you contract after contract that says, if you’re going to do that, you can bill it as a 9110. Why? You got me out of pain. Next patient that calls up and comes in says, hey, Dr. Rich, you know, my gum is sore over here, and you take a look and it’s a broken toothpick and you flick it out. Ok, what did you do for me? A 9110 as opposed to curettage. Now, two things about this code to remember; then I’ll give you a bunch of other examples. One, it can stand in the place of other codes. By that I mean, in a contract 3221 or 9110, I choose 9110 as long as you have documentation. Why would I choose 9110? Because most companies don’t pay for the pulpal debridement, and 3221 is also what we call a take-back code. So you will decide to do the endo next week and you bill it off and get paid for the 3221 by the insurance company, well, guess what? We bill for the endo, ok, we’ll pay for the endo, but we’ll take away what we paid for the 3221; they normally don’t do that with palliative treatment. Second piece, first patient took you an hour, second person took 10 minutes. You can have a floating fee schedule with that code, and that’s not a problem at all. It’s understood

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by the industry. I have a question for you. Are you ready for this one, Rich?

Richard Madow: Sure.

Paul Bornstein: Okay, I come in and, gee whiz, I got this toothache, and you do the treatment like I just said. You did the pulpal debridement or you flicked out that piece of toothpick. You examined me when you did that, correct, and made that decision. Can I bill the 0140, which is a limited oral evaluation or emergency exam along with the 9110? Can I do that?

Richard Madow: I’m gonna say, absolutely.

Paul Bornstein: You bet your life. Most dentists don’t. About 20% of the companies pay. Now, you’re talking $70, $80, $100 bill. How many physicians are going to touch you without looking at you? Well, bottom line, bill for it. Now, patients are going to get mad sometimes because insurance says you’re only allowed 0’s for the year and that is going to affect the 0’s. It doesn’t matter. The mantra constantly is you bill for what you did and educate your patients to the fact. You got to change how you do things if you listen to me on this tape and/or hear me lecture and all the other things I do, that’s fine; get over it. And the reality is, tell the patients we’re required to do because of the new high-tech law or HIPAA, and/or the Affordable Care Act, we have to bill for what we did. We can’t do anything else. We have to do that.

Richard Madow: It should be the other way around. If you give, if you do a 9110 without a 0140, you should be going to jail, because how can you do treatment without an exam?

Paul Bornstein: You and I are in agreement. However, the plans are not written that way. Some are, and that’s a good thing that they are. You have to understand, and this is another whole part of the course, the way that all plans are written, the dollars paid out; the national average is between $250 to $300 per year, per patient. That’s all that’s ever paid out. Premiums are based on that. Who makes that decision? The employers, not the insurance companies.

Richard Madow: Wow, that’s a really small average. I guess most people don’t even go, right?

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Paul Bornstein: That’s the way it is. Richard Madow: One more code on our list and then we’ll maybe get into

some fun FBI trivia before we have to sign off. But you mentioned the 4341 already, the scaling and root planing by quadrant, and there’s kind of the little baby brother for that, the 4342, when you scale only a few teeth in a quadrant. What’s so great about that one?

Paul Bornstein: It’s the number one loss of income to the general dentists in this country. Anyone listening to this tape can pick up $10,000 to $20,000 off what I’m about to say, every year, and that is, patients come in... Imagine I’m your patient, and I’ve being coming in for years, and my mouth is always in great shape, and you do PSR or hygienist does, and which is a spot probing, and I never have any problems and the hygienist says, hey, Paul, between 2 and 3 we found a 5+ pocket, and it was appropriate time for your bitewings, and we found about a millimeter and a half of bone loss; everything else was fine. You come in and examine; everything’s fine, and it comes out to the gal who was doing the billing at the front desk, and what does she do? You got a bill for the 0120 because the doc looked at you, and the 0274 because of the bitewings, and the 1110 because of the prophy, but gee whiz, and you’re going to call it, what? Everybody calls it the same thing: deep cleaning. Was it a deep cleaning? Well, you had, what, 2 mm of bone loss, you had 3 mm of pocket depth, 5 mm of lost attachment. What did you have? You had a 4342 by definition. Most insurance companies believe it or not auto-adjudicate that code and it get paid; that’s what California pays it at 200 bucks a whack...

Richard Madow: That’s the easiest $200 you can make.

Paul Bornstein: It is, but the problem is twofold, one of which, about half the companies, if you bill for the 1110 or the 4342 won’t pay for both on the same visit; therefore, you’re going to lose the cheaper of the two, which is the 1110, and half of the companies do pay. Examples, Delta of Michigan will pay for both at the same time. Delta of Idaho will, Delta of Kansas will, Delta of Rhode Island will pay for the 4342, 75% of the 1110, Delta of California won’t, Delta of New York won’t, and Delta of Florida won’t. That being said, what do I do? Very simple.

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Richard Madow: Move to Idaho.

Paul Bornstein: Move to Idaho. I love that one. I’ve got to tell people that from now on in my lectures. Get an Excel spreadsheet. Okay, I know what companies do, the ones that don’t pay. The ones that don’t pay, we’ll do the 4342, and have the patients come back to do the 1110. It could be the next day, and you’re fine with it as long as your records back up that you did what you said you did on the date you did it. But now you run into the practice management piece where, I’ll be sitting in the chair, and I’ve being coming in for years, and you do the $200 one plus, and my company does... and I have to drag my sorry butt back the next day. Hey, you never had to do this before. What the hell’s going on around here? Bottom line is, oh, we didn’t know oral-systemic connection of periodontal disease the way we do now, and you develop a little mantra. You go to Hollywood and you get a scriptwriter, and everybody is on the same page in your office. This is why we do what we do and we’re saving you and your life, and obviously you get the message. It’s got to be done smoothly.

Richard Madow: I just hate inconveniencing the patient because of an insurance company rule. It’s very distasteful.

Paul Bornstein: Then you might have to charge them out of pocket. These are things you have to decide. You’ll know the patients and you’ll know the insurance companies. I’m telling you, actually, I had a gal that came to my lecture. I was in Miami three years ago, and two years later she shows up in West Palm Beach. She said, I just want to tell the audience, I ran a practice, one dentist, one hygienist. It was great. I moved on, I’m now seven dentists, eleven hygienists outside of Miami somewhere. They weren’t doing the 4342s and stuff. They didn’t know from nothing. She said, I want to tell the audience, I instituted it; now mind you, it’s seven dentists, eleven hygienists. We increased the gross of the practice $600,000 a year for those codes. Yeah, it’s a lot a dentists, but the point being, it’s out there for everybody.

Richard Madow: I think I have the solution for the states that won’t pay for both in the same visit. You have the patient come in at 11:50 PM and you do one of the treatments right before midnight, and then you do...

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Paul Bornstein: It’s not the states. It’s the Delta; it could be Met; it could be Guardian... It just varies from contract to contract.

Richard Madow: I got a quick question for you too. We finished all the codes that we wanted to talk about, which are all really, really interesting to know about, and we increase people’s income just by learning about these codes. How about the old dilemma? Patient is a mild to moderate perio patient, so they come every three months. Is there ever a good solution to that one?

Paul Bornstein: Again, it goes down to one of two things. Either the patient has a history of scaling and root planing, and you have done it, and the American Academy of Perio says, if the patient has had two quadrants of scaling and root planing, 4341, then they are entitled to a 4910, 4910 being the perio maintenance, and some plans will pay every three months, some will pay every six months. The old story, once a perio patient, always a perio patient. I think that is what you’re talking about. Now, leading into maybe they weren’t, and now they would have to have a prophy every three to six months. Actually, a lot of companies now, the new contracts pay for prophies, if the patient is entitled to it, four times a year. They have to be the kind of patient that’s either pregnant, diabetic, HIV suppressed, something, and then they will be entitled to four a year. And remember, the employer made that decision. But in reverse, amazingly, in January 2015, three Deltas so far in the upper Midwest, and I suspect this will go across the country, are now paying for routinely one prophy a year instead of two.

Richard Madow: Ugh. That is pathetic. Paul Bornstein: Well, it’s keeping it to $300 per patient and keeping the

premiums down. The _____ company, that’s the insurance I want to buy.

Richard Madow: I’m just, like, picturing this horrible scenario where the male dentist of the female patient, look, the only way we can get four cleanings paid for per year is if you remain pregnant all year, and it’s a part of my job, you know, the whole scenario is just not...

Paul Bornstein: That’s not bad, and I like that one.

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Richard Madow: You’re going to steal so many lines from this interview, I can tell.

Paul Bornstein: I’m going to use that one in my lectures.

Richard Madow: They are all up for grabs. My pleasure. So anyway, hey, we’re almost out of time, but I know you insinuated earlier, I’ve been intrigued by this. There’s some really interesting FBI or CIA or KGB stories you can tell about dental insurance. What are some of the...

Paul Bornstein: KGB I don’t know about. Let me go back to the 17 million-dollar case I told you settled for 39,000. And I just got another phone call from another doctor in Texas. They only want 24 million from him. Bottom line, Medicaid, and I’m using Medicaid as an example how you have to keep your records. This doc did a whole bunch of stainless steel crowns in the hospital on these underserved kids, bottle caries, their mouths were a mess, 1, 2, 3 years old, and the state said, you did way too many. Did the work have to be done at that moment in time, and we want all our money back from that five years, how about everything you have ever done for all of these patients, and that’s how it works. It’s nuts. And she said, but they really needed it. And they said, no, if they only had a DO, you should have only done the DO, and we want all our money back for stainless steel crowns. However, the state used the guidelines of the American Academy of Pedo, and they said, for a couple of different issues, and I had to find the guidelines of America Academy of Pedo, and say, guess what, they say if the kid is underserved, the parents don’t get it, and they’re only going to come back in three years and have to go under general anesthesia again. The kid is best served by doing stainless steel crowns, even if it is a small, two-surface interproximal, and that is some of the ammunition you had to build up. You could talk about FBI cases all day long. I got a case that I was involved with. This is how bad things get. This is a bad-dude. Sacramento, California, the lawyer calls me on the phone. Doc’s up in front of the board to lose their license and he was looked at by some dentist at the University of California, and he was doing crowns that didn’t have to be done, and so forth and so on. They send me all the X-rays, which I have on my computer. This guy was doing virgin teeth, virgin molars, doing endo, post and crowns. Why? Up in San Francisco, because UPS has a

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contract up there, no lifetime maximum, and he would tell everybody, going back to discounts again, hey, you need six crowns. I won’t charge you anything out-of-pocket. Now, you’re a trusting patient. This guy was doing completely unnecessary dentistry, and he was just filling his pockets and basically doing endos and crowns on virgin teeth. He is going to go to jail.

Richard Madow: And he should. Then he’ll be the prison dentist.

Paul Bornstein: He should, but these creeps are out there, and they are doing this stuff, and I can go on and on and on about the FBI, literally, cops, and state dental boards forever, and some of the stuff I’ve seen.

Richard Madow: This is a weird question but I’ve always been kind of curious about this. There was an endodontist and he’s long retired. I think he lost his license. He was in my area, and of course I’m not going to mention any names. He had this reputation. You would send him a patient, endo on tooth number 30. He would call you and say, hey, Rich, this is Dr. Beep Beep Beep. I just want to let you know the patient is in the chair; they are comfortable; they are numb, they are comfortably numb. I’m about to do the endo number 30. And I’m looking to 31, it has a large MOD amalgam, maybe a little fracture line. Would you like me to just take care of that one too and get it over with? Now, this guy, he’s a creep, but if the general dentist says sure, your call, are they guilty too?

Paul Bornstein: Yes, as far as I’m concerned. But who is going to record it all? Who said what? If the other guy is doing 31, his diagnosis is that it had endo. I guess at the end of the day it would be more the endodontist than anybody else, but frankly speaking, any general practitioner who would send a patient to that creep, after a while, you know what’s going on; you obviously knew.

Richard Madow: You send him a couple of patients, the same thing happens; then you just send them to someone else. Anyway, Paul, we’re just about at the wrap-up point. I don’t know if you have any concluding comments, but before any of that, I just want to let people know, probably many of our listeners are thinking, hey, I have a question and I need to get a hold of this guy. I want to hire him as a speaker. I need him as a consultant, whatever it is. If

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anybody wants to reach you, how will they get in touch with you?

Paul Bornstein: Two ways. I’ll give you my cell phone number, which is 508-380-1046, and I’ll give you my email, which is paulborn@madriver.com.

Richard Madow: Fantastic, and I’m sure you’ll be glad to answer questions here. What are some of the more extensive things you can do for people who are interested?

Paul Bornstein: More expensive?

Richard Madow: Not expensive. Extensive. In other words, what are the typical things you do for your dental clients?

Paul Bornstein: One of the things I like to do for people that’s probably one of the lesser expensive things I do is what we call a frequency analysis. In other words, off of your software, Dentrix, Easy Dental, you can run a frequency analysis of every code that you bill for a year, how much you charge, and then of course I have your zip code. What I will do from that, is I’ll take a look at it and compare it to national statistics, and almost 100% of the time I can tell a doctor the codes that are being flagged, that are being watched by the insurance companies, just by looking at his frequency analysis and where you’re losing money because I can tell where you’re not billing enough of a specific code. When I do that for docs, after that, I spend an hour on the phone with them. They can ask me questions or maybe even do something like what we’re doing right now for an hour, and the docs love it when I do it. I know I make them a lot of money and I get rid of a lot of their fear because they understand what they have to do correctly. Basically, I individualize it for every practice, and it is very easy to do once I have a frequency analysis.

Richard Madow: Sounds like time very well spent.

Paul Bornstein: I think so.

Richard Madow: Absolutely. Hey, we can’t wait another ten years to do this again. Let’s do it soon. I know the information is changing. I know you do a six-hour lecture, so you have many, many more hours of information to share with everybody. But I think we crammed a ton of great stuff in this hour. I really

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appreciate you, and just for our listeners, I want to let you know, to schedule Paul to do this interview took months. You’re busy like every second. Your schedule is ridiculous. I really appreciate that you found the time to help all of our listeners. I know they appreciate it too.

Paul Bornstein: Well, thank you very much, Rich. Hello to everybody, and I’ll be in Baltimore. You can look up Cross Country Education if you want to just come to the lecture. Sometime, you can look them up online. I can’t remember, but I know I’m going to be there in the spring sometime. Just look up Cross Country Education, and I’m like flies on you-know-what...

Richard Madow: Fantastic. Once again, our guest today is Dr. Paul Bornstein. Some really interesting stuff. You really kind of keep it fun and fast-paced, which is a breath of fresh air, so to speak. So, for Dr. Paul Bornstein, I’m Dr. Richard Madow. We will see you in a few weeks on the next edition of the Madow Brothers audio series. Thanks, everyone.