Health Care attorney, Daniel Schulte, discusses whether reports to the National Practitioner Data Bank may be made in an effort to collect in a billing dispute in the latest issue of The Journal of The Michigan Dental Association (February 2022).
Question: A dental plan administrator recently audited my practice. It looked at claims over the last six years or so. They said that I billed before procedures were done and used incorrect codes. The dental plan administrator has threatened to make a report to the National Practitioner Data Bank if I don’t agree to settle and repay a large amount. I don’t feel I’ve done anything wrong, and I think this is a scare tactic. It says a report will jeopardize my continued participation with other dental plans I participate with. Can a Data Bank report be made over a billing dispute when no problems with the quality or appropriateness of the treatment I provided have been made?
Answer: The technical reasons discussed below notwithstanding, no one should use a Data Bank report as a bargaining chip in a negotiation to resolve a dispute. The Data Bank was created for use only by certain entities, for example, medical malpractice insurers, hospitals and other health care entities, certain professional societies, a health plan, certain federal and state agencies, etc. The purpose of the Data Bank is to act as a clearinghouse to collect and release reported information about the professional conduct of health care professionals. Those who are required to report the the Data Bank by law should do so regardless of the effect it may have on a negotiation.
I believe the answer to your question is “no” for two reasons. First, adverse actions taken based only on past billing practices should not be reportable because they do not involve your professional competence or conduct. You should clarify that the dental plan’s allegations are based only on billing (using the wrong procedure code, untimely submitting claims, using an improper claim form, etc.) and are not based in part on the quality or appropriateness of the services you provided (the treatment provided was not necessary, was below the standard of care, your treatment records were incomplete, you should have used different materials, etc.). If the allegations are purely that billing was improper for some reason but there are no allegations involving your professional competence or conduct, then the allegations would not be the proper subject of a Data Bank report.
Read the complete Q&A in the Journal of the Michigan Dental Association on page 26.
About the author:
Daniel J. Schulte has more than 25 years of experience helping clients solve tough problems and capitalize on opportunities that require a blend of business and legal expertise. His practice focuses on addressing the legal, business, licensing, and regulatory challenges of health care professionals, organizations, and facilities. Dan understands how legal issues impact business objectives and, as a result, offers his clients practical, results-oriented advice. He is a Certified Public Accountant, former managing partner and current executive committee member of the firm. Dan also serves as co-chair of the firm’s Health Care Practice Group.
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