Fraud is the misrepresentation of material facts that causes harm through deception, and can be either civil or criminal. Most cases of civil fraud are filed on behalf of someone, either a person or a business, who claims they were damaged by the purported misrepresentation. Cases of criminal fraud are usually brought by local, state or federal prosecutors who believe they have sufficient evidence to prove the misrepresentation occurred, was intentional, and was committed for material gain.
For example, in dentistry, a charge of fraud, either civil or criminal, can be brought against a dentist who signs off on notes in a patient’s record that inaccurately claim procedures that weren’t performed. The best way to prevent this from happening is to carefully review and confirm the information in each patient’s chart before signing off on it.
Fraud can also be committed against the practice itself by unscrupulous staff. One way to safeguard your accounts is to have one employee process only accounts payable and another process only accounts receivable, with neither involved in the other side of the money trail. Allowing one person to handle both functions makes it easier for them to juggle the books and hide the details of any money they’ve siphoned from the practice.
If an unscrupulous staff member commits fraud against a government program like Medicaid, a dental practice with a compliance program in place will be better able to defend itself.
The U.S. Department of Health and Human Services Office of Inspector General (OIG) provides the following PDF titled Health Care Compliance Program Tips.
The Seven Fundamental Elements of an Effective Compliance Program
- Implementing written policies, procedures and standards of conduct.
- Designating a compliance officer and compliance committee.
- Conducting effective training and education.
- Developing effective lines of communication.
- Conducting internal monitoring and auditing.
- Enforcing standards through well-publicized disciplinary guidelines.
- Responding promptly to detected offenses and undertaking corrective action.
More information is available through the Federal Register: OIG Compliance Program for Individual and Small Group Physician Practices.
See the checklist of Do’s and Don’ts in the Additional Resources below as a guide to help you determine if fraud might be taking place in your office and to take step to prevent it from occurring.
Additional Resources:
- Notice on OIG Compliance Program for Individual and Small Group Physician Practices (PDF) The U.S. Department of Health and Human Services Office of Inspector General’s Federal Register
- Dos and Don’ts If You Suspect Fraud (PDF)
- The ADA Guide to Protecting Your Dental Practice From Fraud (ADA Store)