Dental offices, like any other healthcare provider, must adhere to strict compliance regulations to avoid significant penalties. The Office of Inspector General (OIG) has the authority to exclude individuals and entities from participation in all federal healthcare programs, including Medicare and Medicaid. A dental practice that fails to perform proper exclusion screening is at risk of severe financial and legal repercussions.
Reasons for OIG Exclusion in Dentistry
OIG exclusions in dentistry often stem from violations that are unique to the practice’s operations. While some offenses apply across all healthcare sectors, certain areas are particularly relevant to dentists. These include:
- Federal Healthcare Program Fraud: This is the most common reason for exclusion. It includes submitting fraudulent claims to Medicaid or Medicare for services not rendered, performing unnecessary procedures, or upcoding. For example, billing for a complex procedure when a simple filling was performed can lead to an investigation and exclusion.
- Patient Abuse or Neglect: Any conviction related to patient abuse or neglect can result in a mandatory OIG exclusion. This is a serious offense that can include physical or verbal abuse, or providing a substandard quality of care.
- Controlled Substance Offenses: Given that dentists often prescribe controlled substances for pain management, felony convictions related to the unlawful manufacture, distribution, or dispensing of these substances can lead to an exclusion.
- Default on Federal Student Loans: A unique finding for dental professionals is the high rate of exclusions due to defaulting on federal health education loans. In 2017, this was a significant reason for OIG exclusions against dental professionals, far higher than for other healthcare providers.
- License Revocation or Suspension: When a state licensing authority revokes, suspends, or otherwise disciplines a dentist’s license, it can trigger a permissive OIG exclusion. This is a key reason why it’s vital to check state-specific exclusion lists in addition to federal ones.
Why Dental Offices Must Screen
The consequences of employing or contracting with an excluded individual can be devastating for a dental practice. These consequences include:
- Civil Monetary Penalties (CMPs): If a dental office unknowingly employs an excluded person, it can face penalties of up to $20,000 per item or service provided by that person. This applies even if the practice was unaware of the exclusion. The OIG can also seek penalties if a practice bills for services provided by an excluded individual.
- Loss of Federal Funding: Any services provided, ordered, or prescribed by an excluded individual cannot be paid for by federal healthcare programs. This can result in significant financial loss and disrupt a practice’s cash flow.
- Reputational Damage: OIG enforcement actions are public. A finding of non-compliance can severely damage a dental practice’s reputation, leading to a loss of patients and trust within the community, especially in smaller towns like Rossville, Maryland.
- Expanded Liability: The OIG can impose penalties not just on the excluded individual but also on the dental practice owner, managers, and anyone else who knew or should have known about the exclusion.
Who to Screen and When
A dental office’s exclusion screening program should be comprehensive and continuous. It’s not enough to just screen dentists. The practice must screen all employees, including dental hygienists, dental assistants, office managers, and administrative staff, as well as any contractors or vendors that provide services billable to a federal program. Since the OIG updates its list monthly, screening should be conducted before hiring and every 30 days thereafter to catch any changes in exclusion status.