Healthcare’stoothache: Inappropriate billing in dentistry

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Lone wolf vs organised crime?

Over the past decade, OECD has continuouslyrepeated how important it is to stop healthcareexpenses from absorbing an ever increasingpercentage of GDPs in order to avertbudgetary calamities in Europe.

The European Healthcare Fraud andCorruption Network, for it’s part, has notstopped insisting that fighting fraud, waste andcorruption in healthcare is an important andeffective step for governments and for privateinsurers setting up cost cutting strategies inorder to stop financial losses without reducingaccess to quality care.

One might wonder how effective counter fraudactivity in healthcare really is.

Do special investigation units (SIU) in public andprivate health insurance really generate thedesired effect in terms of considerable lossesdetected and monies recovered in line withwhat fraud loss measurement exercises ‘predict’?

In Europe, healthcare fraud is often mistakenlyseen as an occasional offense committed onlyby individual perpetrators and with lowfinancial impact.

Evidence of healthcare fraud revealed in areport recently published by the BelgianMedical Evaluation and Inspection Department(or MEID – the government healthcare fraudwatchdog) does not support this assumption.

Two of MEID’s investigations demonstrate thathealthcare fraud can also be large-scalemalpractice by reputable hospitals or commonpractice amongst a large group of homenurses. The scale of the fraud detected byMEID was considerable and well planned, bothin home nursing and medical imaging.

• In 105 Belgian hospitals targeted by MEID, 13medical imaging departments wrongly billed75% of their petrosal CT scans: between 1March 2013 and 31 August 2014 protocolsshowed evidence of cheaper scull CT scans orthe cheaper facial massif CT scans actuallycarried out instead of the more expensivepetrosal CT scan.

• - This systematic misrepresentation, totaling€2,849,000 was judged to be intentional.

• - 12 out of the 13 hospitals admitted the fraud.

• An annual turnover exceeding €200,000 isconsidered to be practically impossible inBelgian home nursing.

• - Nevertheless the number of home nursesgenerating a revenue exceeding thisamount has been increasing: 136 in 2013 and 187 in 2014 of which 39 generated animplausible turnover of €300,000.

• MEID started an investigation of revenuesbetween 1 January 2012 and 31 May 2015 andtargeted 87 home nurses with a turnoverexceeding €200,000.

Healthcare’s toothache:Inappropriate billing in dentistry

By Paul Vincke - Managing Director, EHFCN

• - Evidence showed that 62 home nurses billedhealth insurance in excess of €3,000,000 intotal.

• - 58% of them over-scored for more than€25,000, 25% for less than €10,000.

• - 26% of the infringements detected relatedto care that was not provided: plain fraud.

• - Other important anomalies detected relatedto inappropriate billing for complex woundcare and performing acts without the properqualification.

Fraud in dentistry: Common practice?

Both cases demonstrate how the same kind offraud is perpetrated by a considerable numberof healthcare providers as if it were ‘commonpractice’ in a particular area of care delivery.

In both cases the group of fraudulent outliersshowed explicitly on the MEID radar whenanomalies were screened in the ‘risk areas’ ofCT scanning and home nursing.

Detecting anomalies becomes extremelydifficult when, in a particular area of interest,the cluster of fraudulent outliers blends withthe whole group of practitioners.

This is in particular the case in dentistrywhere,for example, inappropriate billing practicesrelated to dental fillings and coronal restorationsseem to be common practice for a particularnumber of dentists.

Recent reports published in Germany (HealthInsurer Barmer Gek – Zahnreport 2015) andBelgium (MEID – Restorative dental care 2015)demonstrate how billing for non-delivered carehas become standard procedure in dentistry.

This hampers effective screening for fraudulentoverconsumption, as indicators for non-delivered care will not reveal a group of outlierswithin the targeted sample of practitioners.

Additionally, investigators are confronted withthe difficulty of producing tangible proof offraud; in most cases examination of thepatients’ mouth is the only way to showevidence.

Nonetheless, the challenge remains to stophealth insurance budgets from bleeding whenreimbursing for dental fillings and coronalrestorations.

Methodology to stop the bleeding

In the referred-to MEID report oninappropriate billing in dentistry, two specificinvestigative approaches have been used todetermine the nature of the fraud.

These methods have also allowed the creationof specific indicators to determine the extentof the fraud.

Both the nature and the extent of thefraudulent billing can thus be establishedwithout having to demonstrate the materialproof with dental photography or other timeconsuming techniques that sometimes appearto be useless such as the extraction of teeth.Composites and GIC glass ionomer cement areoften radiolucent and not visible to the eye oreven on X-rays, or patients do not recall thedental care received.

The methods deployed were the following:

Investigative method 1: Restorative DentalCare: Repeated billing for interventions on thesame tooth.

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A population of 7,176 Belgian dentists has beenscreened on how they applied conservingdental care between 2007 and 2009, inparticular dental fillings and coronal restorationapplied on the same tooth of ambulatorypatients over 15 years old, with repeated billingin 1 year (by the same dentist).

The ‘repetition rate’ (RR) was defined as:

• The number of interventions for the sametooth, repeatedly billed in the period ofreference and within 1 year (numerator).

• The number of all the interventions billed inthe period of reference (denominator).

In the Barmer ‘Zahnreport 2015’ (as referred toearlier) an average repetition rate of 8.5% wasthus concluded for 17 million dental restorationsanalysed between 2010 and 2013. Theserestorations had a lifespan between 8.7 and10.5 years but one third of these restorationswere repeated within 4 years.

The Belgian MEID ‘Restorative dental care2015 report’ concluded, after excluding social,economic and geographic factors, that arepetition rate of more than 10% was to beconsidered as inacceptable:

• Or the dental care is not actually provided(incorrect billing).

• Or the restorations are of very low quality(overconsumption or unnecessary expensivecare).

Subsequently MEID started a campaigninforming 1,000 dentists with a >10%restoration rate of the fact that they wereconsidered to be outliers.

This resulted in an important change ofattitude within the targeted group after anobservation period of 1 year: 80% of all dentistswith initially >10% restorations reduced theirrestoration rate to <10%.

The impact on the budget was a €8,500,000reduction or 4.7% of the total budget forconserving dental care.

After a second period of observation 174hardliners were requested to repay amountsup to €15,500 individually and were sanctionedto a fine up to 200% of the amount repaid.

Investigative method 2: Determining aminimum duration for types of care and themaximum amount of reimbursable care.

Apart from the repetition rate, the time spentby the dentist on specific dental care such asrestorations and root canals is also consideredto be a relevant indicator for fraud andunnecessary expensive care (overconsumption).

• In a first phase academic referents and courtexperts have determined the minimum timerequired for restoration of a 1/2/3 surfacecavity (1S/2S/3S).

• In a second phase the time as indicated in thedentist diary was set against the expertopinion.

• - This resulted in for instance the followingfinding:

Time as inDentist diary

Minimum Timeas set by Expert

1S 3 minutes 24 minutes

2S 5 minutes 30 minutes

3S 5 minutes 39 minutes

Crown 7 minutes 55 minutes

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• - In this particular case these time differencesgenerated a fraudulent surplus billing fornot provided dental care of €360,000 overa period of 2 years.

• In a third phase the technical dental board(mainly composed of representatives ofdentists) has elaborated a ceiling system forbilling in a fixed period, creating the value ‘P’:

• - P-value reflects the minimum (expert) timeand complexity of the dental care concerned.

• - P-value also reflects the cost of thedisposable equipment used.

• Finally it was decided that P values will concernonly the extreme outliers exceeding theceiling P200.

• - As a result, all dental care billed in excess ofthe P200 ceiling during a period of at least30 days, with a minimum of 6 reimbursedacts a day, is considered to be non compliantwith this new billing rule as explicated in apiece of new legislation.

This new monitoring system will eliminate therequirement of demonstrating evidence offraudulent intention in every single suspiciouscase and will stop 100 out of the 7,200 Belgiandentists from eating 5% of the dental care budget.

[Off the record: according to JeremyHetherington-Gore (Tax-News.com, London29 November 2000) before the financial crisisit was traditionally Belgian dentists who werethe mainstay of the Eurobond markets –wealthy professionals in a high-taxing countrywho kept their money in lock-boxes under thebed and used it to buy bearer bonds which paidinterest gross into offshore bank accounts, noquestions asked.]

By Paul Vincke

About EHFCN https://ehfcn-powerhouse.org/welcome

EHFCN was formally established in 2005 as anot-for-profit international association byBelgian law.

The Network is membership based. The 16members from 14 European countries representpublic and private healthcare insurers, healthfinancers and payers who all have thecountering of fraud, waste and corruption inhealthcare as their core business or as part oftheir mission.

The aim of EHFCN is to improve Europeanhealthcare systems by reducing losses to fraud,waste and corruption, and its objective is tohelp members to be more efficient andeffective in their work of prevention, detection,investigation, sanctioning and redress ofhealthcare fraud, waste and corruption, withthe ultimate goal of preventing money beinglost and returning money to healthcare servicesfor the benefit of every patient.

EHFCN provides its members with high qualityinformation, tools, training, global links andaccess to professional consultancy. It alsopromotes the share of good practice, joint work,bilateral agreements and the development ofcommon working standards.

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Fraud is a challenging problem no matter whatsector it impacts on. Its economic effects areclear – worse public services, less financiallystable and profitable companies, diminishedlevels of disposable income for all of us,charities deprived of resources needed forcharitable purposes. In every sector of everycountry, fraud has a pernicious impact.

However, in the healthcare sector there is adirect, negative impact on human life.Whatever country we live in what we all havein common is that our people want and need tobe healthy. There are healthy people who fearill health, sick people who yearn to be well,older people who want to enjoy their lateryears and young people who need thefoundations of lifelong good health.

At present we have a fraudulent or corruptminority who are prepared to divert the funds

which are intended to keep us all well. Thatminority exists in all countries – and even in theUK’s National Health Service (NHS). Everypenny lost to fraud and corruption drains thelifeblood from our healthcare systems andundermines their capacity to provide essentialtreatment.

PKF Littlejohn and the Centre for CounterFraud Studies at University of Portsmouthhave published the latest global (and UK)research concerning the extent to which thishappens – ‘The Financial Cost of HealthcareFraud Report 2015’.

The Report doesn’t just look at detected fraudor the individual cases which have come to lightand been prosecuted. Because there is nocrime which has a 100% detection rate, addingtogether detected fraud significantly under -estimates the problem. The Report also doesn’t

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The real cost of healthcare fraudJim Gee, Partner and Head of Forensic and Counter Fraud Services at PKFLittlejohn sheds light on the impact of fraud on the healthcare sector…

rely on survey-based information where thoseinvolved are asked for their opinions about thelevel of fraud.

Instead it considers 107 statistically valid andhighly accurate loss measurement exerciseslooking at the total cost of fraud (and error). Thedata considered covers 17 years and 14 differenttypes of healthcare expenditure in differentcountries, with a total value of £2.9 trillion.

Across this massive global dataset it showsaverage losses of 6.2% with 88% of the lossmeasurement exercises showing losses ofgreater than 3% and an increase of almost 11%in this cost since 2007.

In the UK’s NHS, the report looks at losses in 6areas of expenditure and 3 of patient chargeincome, using the NHS’s own data where it hasmeasured losses or global data where it hasnot. Total losses for the NHS (for fraud alone)are estimated to be between £3.73 and £5.74bndepending on the assumptions made – eitherway an enormous sum which is not beingdevoted to patient care.

In the context of the NHS having to makeefficiency savings over coming years and theannual pressures for additional expenditure asnew treatments become available, this is a costwhich the NHS needs to do more to manageand minimise. The report cites the periodbetween 1998 and 2006 when the NHS did justthis – reducing the cost of fraud by up to 60%and delivering £811m of financial benefits tofund better patient care.

“At present we have a fraudulent or corruptminority who are prepared to divert the fundswhich are intended to keep us all well.”

So what is to be done? It is the view of theauthors of the Report that there are 3 firststeps for the NHS to take to reduce the cost offraud:

1) The NHS needs to re-adopt an approachwhich is focussed on reducing the cost of fraudnot just investigating and prosecutingindividual examples (although this is importanttoo);

2) It therefore needs to re-commence lossmeasurement exercises across key expenditurestreams. It is only with accurate knowledgeabout the nature and extent of fraud thatproportionate, effective action can be taken toreduce its extent; and

3) It needs to re-create a powerful, well-resourced organisation to lead this work with aremit and authority across all parts of the NHS.

This is an urgent task for those who managethe NHS. It is hoped that the report providesan evidence base for renewed action to protectit as it needs to be protected.

Jim GeePartner and Head of Forensic and CounterFraud ServicesPKF LittlejohnTel: +44 (0)20 7516 2288jgee@pkf-littlejohn.comwww.pkf-littlejohn.com

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Jim Gee, Partner and Head of Forensic and Counter Fraud Services

EDITORIAL FEATURE

Paul Vincke

Managing Director

European Healthcare Fraud and Corruption Network

www.ehfcn-powerhouse.org/welcome