A little bit of fraud is OK, isn’t it?

Fudging the facts in your favour, creative accounting or tinkering with records after the event is, unfortunately, often uncovered when reviewing cases. Dr Annalene Weston, Dentolegal Consultant at Dental Protection, reflects on the ethical slippage that can lead to the belief that “a little bit of fraud is OK”.

Case one

Dr N, a recent graduate, bought a practice with a long-standing patient base. The staff remained and the transition was smooth. Many of the patients required indirect restorations and business was booming. Dr N did, however, begin to notice a pattern of patients without major dental cover requesting that they be charged for five surface fillings up to the value of a crown rather than the crown code, to enable them to maximise their rebate. They advised Dr N this was always the case at the practice, and they couldn’t afford their required treatment without. Dr N reflected on it and formed the view that the patients did need the care, and they paid their insurance premiums on good faith. Really, it made sense to help them financially as best as he could to get the treatment they needed, didn’t it?

Case two

Dr M provided treatment for patients via a voucher scheme organised through the local health authority. The vouchers often did not cover the full treatment costs, leaving Dr M providing a significant amount of work for no fee. Dr M therefore felt it a reasonable step to increase the number of tooth surfaces on the claims for patients who attended for a single filling only, to increase the money received on those matters. Dr M was still providing more free treatment than they were claiming for, so they believed this to be a reasonably fair approach. After all, in Dr M’s mind this billing pattern hurt no-one and enabled Dr M to provide the full range of treatment to those required, whose voucher funds fell short. Dr M believed he was transferring the funds between the patients to ensure the best outcome for all.
 

Case three

Mr P, an OHT, was the sole practitioner working in the clinic when Mr S walked in seeking emergency care. Mr S advised he had had an extraction two days previously and he was in significant pain. He requested a medical certificate for five days off work. Mr P examined Mr S, and saw evidence of a recent extraction but everything generally looked OK, and Mr S didn’t really seem to be in any pain. Nevertheless, he wrote the certificate for five days off work as requested, as it felt like a smart practice builder to do as Mr S had asked.

Discussion

Are you reading this with disbelief, wondering why Drs M, N and Mr P would make the decisions they did? Are you perhaps wondering if I am making these cases up? Regretfully I am not. Each of these practitioners have recently contacted Dental Protection for assistance, following these circumstances. Their contact was not borne from a sudden pang of conscience, or to seek guidance to undo what they had done, but rather because a third party had uncovered their ethical fade and was now asking difficult questions. With the benefit of hindsight, each of these individual practitioners realised to their horror that the third party was NOT going to like the answers they had to give.

 

The Dental Board of Australia expects that practitioners “display a standard of professional behaviour that warrants the trust and respect of the community. This includes practicing ethically and honestly”.¹ They go on to say that practitioners “must be ethical and trustworthy. Patients trust practitioners because they believe that in addition to being competent, practitioners will not take advantage of them and will display qualities such as integrity, truthfulness, dependability and compassion”.²Failure to demonstrate these behaviours can lead to the Dental Board forming the view that you are not a fit and proper person to practice, as you do not have the necessary rectitude of character.³ 

While Mr P in case three had not falsified records per say, their poor judgement was frowned upon by the Dental Board, and their justification believed to be weak. A caution followed, accompanied by conditions to undertake six hours of Board approved CPD in ethics. This condition was displayed on Mr P’s registration for all to see.

The billing practices of Dr N and Dr M led to the revocation of their provider privileges with health funds and voucher schemes respectively. Dr N was unable to practise without the ability to utilise HICAPS and was forced to close. Dr M suffered significant reputational damage as patients who requested vouchers to seek care at his clinic were told in no uncertain terms he had been “removed from the scheme”. They drew their own inferences from this.

Learning points

I hope that these case summaries have highlighted that even a little bit of fraud is definitely NOT OK. It is interesting to note that if any of these practitioners had been asked prior to their contact by a critical third party if they had committed fraud, they would have said no.

While those with the billing discrepancies genuinely believed that they were enabling the patients to access vital treatment by billing the way that they were, they forgot that they were actually focusing on how the patients were going to pay THEM for the treatment. So while their intentions may have been noble, the fact that their focus remained on their bottom line shines a very poor light on them.

Inaccurate records will always lead to a finding of unprofessional conduct by the regulator as it is considered unacceptable.

 

References