A Very, Common Blooper in Dental Medicaid Audits

“To err is human…”  Alexander Pope

Remember that show “TV”s Bloopers and Practical Jokes?” I think Dick Clark was in it (maybe not…it was a long time ago…I watched reruns). Anyway, I remember laughing so hard at some of the bloopers.  I also like when, after a movie is over, the director highlights the casts’ bloopers. Something about watching someone else mess up that makes me realize everyone is human.

But accidentally erring is completely different (and a lot funnier) than a RAC auditor misapplying a clinical policy, be called out on it, and continue to audit the same erroneous way without regard or fortitude to change.

I have said over and over, no health care provider who accepts Medicaid is safe from the grasp of the over-zealous, under-trained Medicaid auditors. Welcome, dentists, to the “oh-so-ever-interesting-Medicaid-three-ring-circus.”  Here are your Tentative Notice of OverPayments (TNO). And here are your bloopers.

I’ve seen a few common themes in the claim audit findings for a post-payment review of a dental practice, but want to discuss one re-occurring theme…one that has poked its rearing head more than most other issues I have seen, thus far.

RAC auditor recoups the Medicaid reimbursements because: The “attending provider” NPI number did not match the “provider rendering the services” NPI number.

The RAC auditor cites DMA Clinical Policy 4A as the source of the rule that the attending provider and rendering provider numbers must be the same.

DMA Clinical Policy 4A states, in pertinent part, “Enter the attending provider’s NPI for the individual dentist rendering service. (This number must correspond to the signature in field 53.)” (Field 53 is the field for the treating provider).

Yet,wait, young auditor, what year DMA Clinical Policy 4A are you using? 2013? Or the year that is applicable to the date of service (DOS) you are auditing?

Because prior to the 2013 Clinical Policy 4A, earlier 4A Policies read as such: “Enter the attending provider’s NPI for the individual dentist rendering service. (This number should correspond to the signature in field 53.)”

Should versus must….must versus should…

Look at these examples:

Should:

  • People should protect the environment.
  • People should be kind to others.
  • You should go see “Man of Steel;” it is very good.

Must:

  • Thou shall not murder. (Shall is an old form of must, and a bit more British).
  • People must stop completely at a stop sign.
  • You must stop talking!

See the difference? If someone tells me that I should go see an art exhibit, I will say, “Thank you.  I will see if I can fit it in my schedule.”  If someone tells me that I must abide by a rule, I will ask, “What will be the penalty if I do not?”

“Should” denotes a suggestion.  “Must” denotes a command.

So going back to…

“Enter the attending provider’s NPI for the individual dentist rendering service. (This number should correspond to the signature in field 53.)”So…if the number “SHOULD” correspond, then, obviously, the number “MUST” not correspond. Right?

Bloopers are funny. Redundant errors are not.

About kemanuel

Medicare and Medicaid Regulatory Compliance Litigator

Posted on June 27, 2013, in Dentistry Services, DHHS, Division of Medical Assistance, DMA Clinical Policies, DMA Clinical Policy 4A, Legal Analysis, Medicaid, Medicaid Audits, North Carolina, PCG, Post-Payment Reviews, RAC, RAC Audits, Regulatory Audits, Tentative Notices of Overpayment and tagged , , , , , , , , , , , , , . Bookmark the permalink. 2 Comments.

  1. My understanding is an attending provider is the same thing as a rendering provider. So, yes, it is true that the attending provider NPI should match the rendering provider NPI (attending provider = rendering provider). And, the attending provider NPI should match the signature of the provider who rendered the service.

    Perhaps you are confusing attending provider with billing provider. A billing provider is the dentist or practice that receives reimbursement from the payer. Not the same thing as attending/rendering provider.

  2. Attending provider = rendering provider. Sounds like you are confusing this with billing provider. A billing provider is the dentist or practice that receives reimbursement. My understanding is that the attending/rendering provider NPI should always match up with the signature of the rendering provider on the claim. I don’t think that NC Medicaid has changed their perspective on this issue for many, many years. Their position is that they must ensure that the provider who rendered the service is properly credentialed and enrolled.

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