The Dentist and Office Manager are Cheating Insurance Companies

two people's hands holding pens and reviewing some papers in front of laptop computers

Welcome back to The Dental Practice Fixers podcast, dentistry’s most unique show! Today we have a question from a listener asking if the office manager would be liable for falsifying dental records sent to insurance companies if it’s being done under the dentist’s direction. It appears as though this office is having a difficult time getting insurance to approve scaling and root planning so they are fudging the records that are sent to insurance. Listen to what Dave and Rich have to say about this one. Then of course we do the call of the week. A caller who is a potential new patient asks an office if they are having a “Teeth Cleaning Sweepstakes.” Listen in to see how this one was handled! If you have a question that you would like answered on our podcast, please send it in to podcast@madow.com. We will do our best to get yours answered!


Season Two – Episode 6

The Dentist & Office Manager Are Cheating Insurance Companies

Dr. Richard Madow: Hi, I’m Dr. Richard Madow, and welcome to Episode 6, Season 2 of the Dental Practice Fixers Podcast. And this is a really really big day for those of you in Dental Practice Fixers land which obviously you’re in Dental Practice Fixers land that you’re with us today. Those of you listening on iTunes and Spotify and Sketcher and Diesel and Weasel, whatever you’re still on. You might not know this, but if you’re watching on YouTube or some other video server, you can probably tell that this is our first live video podcast of the Dental Practice Fixers. We’ve been all audio up until now finally, Episode 6, Season 2. We’re coming at you and you can actually see us for better or worse. So I’m not sure if that’s better or not but as you can tell, we’re actually in different locations today. So here I am over here, Dr. Richard Madow and over there is my bro, my main man, my business partner and my co-worker, Dr. David Madow. How is it going today Dave?

Dr. David Madow: What is going on? I’m doing feeling fantastic. Rich this is a monumental day in the Dental Practice Fixers Podcast because we’re… I just want to make sure people understand. We’re keeping… it’s still going to be available on iTunes in all of the audio podcast formats. We’re not going anywhere but we’re adding another dimension. We’re doing… we’ve got a video channel setup. It’s called the Dental Practice Fixers on YouTube and you can actually watch us for better or worse, I guess. Watch us as we’re doing these shows. So feel free to go to the Dental Practice Fixers on YouTube. Just do a search for that, it’ll come right up and subscribe. Subscribe and make sure you enable notifications if you’re watching us on YouTube. So, then every time a new episode comes up with just once a week, you’ll get an extra notification. And please interact with us. I think YouTube is probably more… what’s the word I’m looking for. It’s easier to interact with us.

Dr. Richard Madow: Interactive. Maybe it’s more interactive. Is that the word you’re looking for?

Dr. David Madow: That’s the word I’m looking for. So you can comment, you can like, you can comment back. It will feel definitely more interactive. So we’re looking for this YouTube channel to really grow with some help from you of course.

Dr. Richard Madow: Now Dave before we go any further, I do want to point out that our lawyer Goldberg pointed out that we do need to read some instance we’re going on video and that is that if you are enjoying the podcast while driving, we cannot be responsible for anybody watching the video and getting it to any kind of accident. So this whole disclaimer we have to send, courtesy of Goldberg. So if you’re driving, please do the audio only. But if you’re sitting in your office, your home, you’re on the treadmill, you’re at the movies, wherever you are, you can watch this on your computer or any of your devices.

Dr. David Madow: But they could still… let’s say they’re driving and they’ve got their iPod, iPad, whatever it might be, as long as they’re not… if they got only on YouTube only and as long as they give us their word they’re not watching, I think our lawyer said that might be okay.

Dr. Richard Madow: he only said you cannot utilize YouTube. Well we’ll leave that up to the discretion of the listener.

Dr. David Madow: But what about some of our field insurance guys? Are we insured just in case somebody tries to sue us for watching our…

Dr. Richard Madow: It’s funny that you said that because I contacted them yesterday and told them what we’re doing, and he looked through the policy and he said, guess who doesn’t have insurance. So I guess we’re not. So please be kind, rewind. Well that was quite an intro. So again we’re still on audio if that’s the way you want to enjoy it. But if you’re really a glutton for punishment, you can watch us live. I’m on the east coast today. Dave is in mountain time through the magic of electronic technology, here we are all together. So Dave, I understand that you’re got a really crazy questions today that someone submitted.

Dr. David Madow: It’s unbelievable. So we’ll get into right now because it’s

Dr. Richard Madow: Let’s do it.

Dr. David Madow: It’s an incredible question I think, not only can we give a great answer to. I promised this listener that we will give him a great answer too.

Dr. Richard Madow: Great. That’s subjective.

Dr. David Madow: But we can expand on it. I think everybody is going to love this. So I’m going to go ahead and read the question. It’s a little bit on the long side so bear with me. I actually edited it down a little bit too. So okay, here is how the question goes. Hello Madow Brothers, I just left an office that is practicing insurance fraud. That’s good enough already isn’t it?

Dr. Richard Madow: Right on. Let’s just say congratulations.

Dr. David Madow: It gets better. They’re cooking up a double set of records. One pair of your charts for the insurance company and one for the patient. Granted, the insurance companies are being more and more ridiculous about the perio unless there is calculus visible on x-rays. So I get it, I’m kind of talking at her tone. But there are other cases where they say, well if we add a few more millimeters here and a little mobility there, we can submit another quad or two for scaling and root planing. To make matters worse, the doctor tells the office manager to do whatever you need to do to get those treatment plans accepted. I don’t want her to get in trouble, if caught… here’s my question, if caught, is there any way that just the doc alone would be liable or will the office manager be liable too? Name withheld, I request.

Dr. Richard Madow: Good move withholding your name. Let’s just start with that. Now let me just get this straight.

Dr. David Madow: a double set of books here.

Dr. Richard Madow: We’ve been coaching for 30 years, and just when you thought you’ve heard it all, I’ve never heard this before. This is amazing. They are keeping an accurate record for their patients’ treatment sake, but then submitting a completely falsified record, an exaggerated record in order to get insurance coverage. So it’s pretty much what’s going on here.

Dr. David Madow: Yes.

Dr. Richard Madow: And they add extra pocket depth and mobility. Now they don’t add any extra We’ll give them a little credit for that.

Dr. David Madow: We don’t know for sure. They might be adding . That wasn’t really stated so we don’t know exactly.

Dr. Richard Madow: My first comment is will this doctor be comfortable being the prison dentist one day because that’s where they’re headed. Is this what you have to do to get a job as the prison dentist?

Dr. David Madow: I mean, Rich it’s just an unbelievable story. We can go for so many tangents here but let’s… maybe the first, the quick answer. The first quick answer is the office manager liable also. I’m going to say yes. I mean even though it’s under the doctor’s direction, she is falsifying records. It’s illegal.

Dr. Richard Madow: That’s illegal. We’re not attorneys.

Dr. David Madow: I felt we were.

Dr. Richard Madow: I sleep with an attorney every night so maybe it’s starting to rub off for me a little bit.

Dr. David Madow: Oh I don’t know that. Oh your wife, that’s right.

Dr. Richard Madow: I’m going to say the office manager knows this is illegal. And also, again, from what I’ve learned a little bit in living with an attorney, there’s an exact phrase which I can’t recall but it’s something among the lines of just because you don’t know the law, it doesn’t excuse you if you break the law.

Dr. David Madow: That’s very true.

Dr. Richard Madow: You can’t rob a bank and then go to court and say, well I didn’t know robbing a bank was illegal. And then in this case, I’m not even sure how that applies because the office manager knows this is illegal. They’re complicit in insurance fraud. If I’m prosecuting on behalf of the insurance company, I’m going after everyone especially the office manager who’s making these notes to patients. The office manager is falsely claiming and knowingly falsely claiming these records that are true. What a bad situation. Congrats on quitting.

Dr. David Madow: The writer quit but she’s concerned about the office manager is still there. But Rich we can also go off in a different direction because first of all, we would never ever ever recommend doing anything illegal in dentistry or in our lives. So that goes without saying, falsifying record is illegal. But the other direction we can go on is… the basic problem is they’re having a big issue of getting perio cases, scaling or root planing approved. So there’s a reason for that, and I’ll tell you something. I know for sure that if they just maybe submitted things a little bit differently to the insurance, I mean, totally honestly, but let’s say there’s no real visible calculus on the radiograph, but let’s say if they sent a narrative and said you might not be able to see this on the radiograph but there is a ton of information, there’s calculus that maybe can’t be seen, there’s mobility. This person, this patient definitely needs scaling or root planing. This is what I’m recommending professionally and I would even take it to the point where if the insurance company denied it, send another narrative and say you are denying something that is absolutely and medically necessary if this patient gets upset and comes after somebody. You’re going to be named in the lawsuit. You do not want to deny this claim because this patient needs this treatment. And I’ll tell you something, I think the insurance company would reverse their decision very very quickly.

Dr. Richard Madow: I agree. Unless Sonny Lee is the insurance clerk, then they might not. Denied, but I was going to say a very similar thing. It’s all in the narrative. Numbers are numbers. Narrative is narrative. The insurance person cannot see the case and you’ve got to describe to them in detail and this is the one time I love using dental lingo. I would say, I know you agree. Don’t use dental lingo with patients, but with insurance people I love to use dental lingo and make it sound very complicated. So I would describe as complex ways as you can, and have about some photographs. You’re saying that the calculus is not visible in the radiographs. Send some photographs. Send some photographs of perio probably around it. I mean just do whatever it takes to let them know that yes there is perio disease here, and as you said I think it’s great to say and you’re going to deny this patient’s treatment that’s going to save her teeth? Are you willing to be responsible for that? Won’t always work but I love a good narrative.

Dr. David Madow: Yeah. So I think the dental office is going about this totally the wrong way. Trying to make things up and fudge things with a different set of records as opposed to just telling the truth and saying this patient… look, I’m a doctor. You’re an insurance person, I’m a doctor. I’m telling you this patient needs this treatment. If you’re ready to deny this, you’re going to face the consequences if that comes back on. And I’d say 99% of the time the insurance company say okay you got me.

Dr. Richard Madow: I give. You know what’s weird Dave? Is that so frequently we see practices through our coaching that are under diagnosing and under treating periodontal disease. I wonder if this office is actually over diagnosing and over treating periodontal disease. Dental perio claims approved if you really do it right, it’s not all that difficult.

Dr. David Madow: Yeah agree.

Dr. Richard Madow: My gut feeling is they may be pushing their perio cases for a little more than they actually are. Maybe not but it’s possible.

Dr. David Madow: I mean I didn’t think of that but it’s possible because if they’re trying to do scaling or root planing on a ton of patients that have twos and threes, maybe they are. That’s a good point too. But if the patient… if they’re diagnosing the patient who truly needs it, it’s up to the doc and the team there to make the insurance company realize that this treatment has to be done. So we’re going full back to that office. They’re doing something wrong and certainly, falsifying records is really wrong, really not good.

Dr. Richard Madow: Do you remember back in the day when we were in dental school? We weren’t there together. You’re 4 years ahead of me school wise, but…

Dr. David Madow: Oh watch it. Don’t tell anybody that.

Dr. Richard Madow: When we took the Northeast Regional Boards, you had to have like a perfect class two lesion because you wanted to do a gold… in-layer gold foil and I think they have to do it on an amalgam on a class two as well back in the day.

Dr. David Madow: We did.

Dr. Richard Madow: And it was tough to find a perfect one and some people would actually take a graphite pencil and draw a little area in the inner proximal and duplicate the x-ray. I’m thinking, geez this is just… it’s complete fraud. It’s unbelievable. And those are probably the same people that are doing this.

Dr. David Madow: I was ready… the things that you had to get done to get your license.

Dr. Richard Madow: I want to make another comment too. Back when I was in my practice, I remember early on I have a patient pay for… it’s fairly large case. It was large to me in those days. Probably would seem like nothing now in cash. And they handed my office manager Carol cash and said I bet Dr. Madow is going to like this. And then she came to me at the end of the day and totally innocently said, Mr. so and so who paid in cash, do you want to just pocket this? And I said absolutely not. We have to report this income just like everything else. And it’s one of those things where if your team knows that you’re willing to bend the rules, especially rules like that. Tax fraud, pocketing cash. If they know you’re willing to do that, that where you draw the line and where do they draw the line. If you’re willing to do that, well what’s wrong with them taking home a couple of paper clips which leads to them taking home some more office supplies which we…

Dr. David Madow: Toilet paper.

Dr. Richard Madow: Toilet paper, of course. They can wipe you out with toilet paper. And then was that going to lead…well we don’t really need all this …. I’m going to sell some on eBay. Little dishonesties can turn into some big dishonesties especially if they think you’re dishonest or if they think they have something on you so to speak.

Dr. David Madow: Yeah. And let’s close this little segment and I’ll give you my opinion on how I live my life. Rich I’m pretty sure you live your life the same way. We’ve known each other for quite some time. But I just don’t do anything in life that is going to come back and haunt me that I’m going to get a knock on the door from the IRS or anything. It’s easy to cheat a little bit here now on your taxes but why do it. If you do things right, if you follow the rules, nothing is going to… it’s just not going to come back and haunt you and that I think is a great way to live your life.

Dr. Richard Madow: I totally agree. And that doesn’t mean that we’re like total dorks and do things that are crazy and fun and outrageous and pushing boundaries. When it comes to breaking the law of cheating on taxes or committing insurance fraud, you got to be crazy to do stuff like that.

Dr. David Madow: Yup. Don’t do it.

Dr. Richard Madow: Don’t you break my heart.

Dr. David Madow: Are you ready for the call? We got a great… we’re going to do a great call…

Dr. Richard Madow: Before we do the call, I just want to mention something.

Dr. David Madow: Sure.

Dr. Richard Madow: The last podcast, I was talking about Fattmerchant and talking about how it’s the most incredible way to save on your credit card processing. Because they don’t take an overage percentage. They just charge a low monthly fee. No percentage at all. And I said there’s a special page we have. If you want to check out Fattmerchant, start saving money right away. We use it in our office. You should use it in yours. Go to this website and then guess what, I gave the wrong website.

Dr. David Madow: Oh no, ouch.

Dr. Richard Madow: So I think a bunch of people might have been stranded in like some under construction sites. The website still has under construction signs. It seems to be a little anachronistic.

Dr. David Madow: I think it probably depends on the website and the host I’m guessing.

Dr. David Madow: Okay. Well this is a very nice host. So here’s the correct website. If you want to find out how to save money, get the best credit card processor with Fattmerchant. It’s B I T.LY/FATTMAD. So Fattmerchant is spelled with two Ts. Madow is spelled with MAD, so we kind of combined little shorten versions and I somehow screwed it up. So again it’s BIT.LY/FATTMAD, that’s it.

Dr. David Madow: And if you’re watching the video version of this on YouTube, if you’re watching this on video, right below we are putting the… any time we give a link or something, it’s going to be written below. So there’s no mistake now. Of course, last episode, when you gave the wrong one, our video editor guy of course took it from the script and he put the wrong one.

Dr. Richard Madow: How dare he.

Dr. David Madow: I know. Can you believe it?

Dr. Richard Madow: It’s almost as bad as committing insurance fraud by exaggerating perio pockets but how it seems to know.

Dr. David Madow: I know. Right?

Dr. Richard Madow: That’s no excuse if they didn’t know though. Right? And there’s no www, there’s no .com. It’s just a cool little shortened thing. BIT.LY/FATTMAD.

Dr. David Madow: And while we’re talking about some really cool things that we are helping you within your practice, really quickly, our mastermind… sorry, our Masterclasses are really doing great. It’s a very small group of people that we invite to a location generally in Baltimore. Occasionally you have to check the website which will be below in one second. We might travel to another city but it’s pretty much we like to do it in our hometown of course of Baltimore. Let’s face it, it’s comfortable, it’s easy for us so that’s what we’re doing. And let’s face the fact that we generally have a group of great docs that come in somewhere between… we have only between 8 and 12 per Masterclass. And it’s way that… one of very intimate basis we can show you exactly from start to finish how we could help you and your practice through dental coaching and we’ve been helping a lot of practices over the last few years. Really go from here to here very very easy. And love when you do so much more. So check out. I’m going to make sure I get this right, and in case I don’t, it’s going to be right here below…

Dr. Richard Madow: Who would ever get a website wrong? You’ve got to be an idiot to do that. Come on.

Dr. David Madow: But this is an easy one. It’s simply Masterclass.madow.com. And it’s written right there. If you’re watching the video version but if you’re still listening on ITunes which is very cool, masterclass.madow.com.

Dr. Richard Madow: Fantastic. Let’s do our call of the week. I don’t know about you. I think these are always the most fun part of the podcast.

Dr. David Madow: Let’s dial up a real good one today Rich. Okay? I’ve got a great concept so hang on one second.

Female Speaker: Hi, how can I make you smile today?

Dr. David Madow: Hi, how are you? I have a question for you. I’m kind of new in town and I know I probably need some work and a neighbor of mine told me… I hope I got the right place so you’ve got some kind of a cleaning sweep space contest going or something like that.

Female Speaker: I don’t think so. I haven’t heard about that. Was it our office?

Dr. David Madow: Maybe, I might be mistaken. It could be my fault. I’m not sure. You don’t have any kind of like contest going for cleanings?

Female Speaker: No we do not. I’m sorry.

Dr. David Madow: Okay. I guess I got to find out who’s doing that contest. I know I need a lot of stuff going. Okay well thank you very much.

Female Speaker: You’re welcome. Have a good one okay?

Dr. David Madow: Same to you. Bye.

Female Speaker: Bye.

Dr. Richard Madow: Wow, what kind of contest? She was a little surprised. You caught her by surprise there.

Dr. David Madow: You didn’t hear about the cleaning sweepstakes in the nation? You didn’t hear about that?

Dr. Richard Madow: We’ve been in… okay let’s back up for a second.

Dr. David Madow: Back, yes I know…

Dr. Richard Madow: I know you’re going to agree. I cannot stand the automated menu stuff. It just screams corporate dentistry; we don’t care. You’re just a number.

Dr. David Madow: That is ridiculous. I mean how large… it’s probably, okay if you’re a new patient press 1, if you’re something press 2, if you have a billing inquiry. I mean how large… I mean it’s going to the same person.

Dr. Richard Madow: If you’re an old patient press 2, if you’re a middle age patient… yeah I agree.

Dr. David Madow: That was ridiculous.

Dr. Richard Madow: Really bad. If you’re so short staffed that you need to have some kind of menu for people to call.

Dr. David Madow: So that part was totally ridiculous and I think most people are going to hang up on those things.

Dr. Richard Madow: I agree. Okay I have something positive to say.

Dr. David Madow: You do?

Dr. Richard Madow: I like the way she answered the phone and just gave her name and said how can I make you smile today. Something like that.

Dr. David Madow: Oh I loved that. I thought she was going to be totally great because when she said that I felt that was fantastic.

Dr. Richard Madow: I agree. Again it’s a different entry. Differentiate or just like we teach practices to say how can I help you. How can I make you smile today? It’s great. She might get some weird answers but still great.

Dr. David Madow: Okay look. I don’t know what else I could have done. I told her I’m new in town. I think I need a lot of work. It’s been a while since I’ve had a cleaning and of course this bogus thing about some kind of sweepstakes contest for cleaning. But oh my god she didn’t take the bait. She just said I don’t think we’re doing that, goodbye. She could have said, well let me tell you something, we’re not having an actual contest going but certainly come on in to our office and here are the reasons why we would take great care of you. Done, game, that’s it.

Dr. Richard Madow: Yeah I’ll say it was a kind of a funny/crazy thing to say which was great and it really caught her by surprise. And you could say well she was so caught by surprise, she was a little bit off her game, but as the call went on after the contest sweepstakes thing. It was already settled that’s not them, she made no effort to get to know you and ask you any questions, say welcome to the neighborhood or we’re not doing a contest but we think you’ll love Dr. , whatever it is, something rather than you called the wrong office, bye.

Dr. David Madow: And I know that this was meant to take her by surprise because she probably never got a call like that before saying are you having a cleaning sweepstakes but my point is though that all day long, people that answer the phone at a dental office, they might be taken by surprise. It might not be that question but it might be something else that they got to be quick at thinking on their feet and she was not quick and she lost a possible patient because of that.

Dr. Richard Madow: Agree. It’s kind of like our old lesson. Anybody that calls your office as a potential new patient, they might say a hundred different things, but it’s the same thing they’re saying and that is out of all the dental practices in your town or your city, I picked your office, I called you, I’m trying to become a patient of your practice, please let me do it.

Dr. David Madow: You forgot to say one thing.

Dr. Richard Madow: I want you to be my dentist.

Dr. David Madow: Agree. That’s basically what they’re saying. What can I do to help you? I want you to be my dentist.

Dr. Richard Madow: Every darn one of them. So why not get that person? Okay so they thought they was some cleaning contest, let’s get them on the appointment book and show them our dental practice is the best.

Dr. David Madow: So since we grade this at the end of every call, I’m going to have to give an F because she had all the ammunition right there. I’m new in town, I need to lot of work. I think I need a lot of work. No effort was made whatsoever. I give her an F. I’m sorry.

Dr. Richard Madow: I’m going to say it wasn’t her fault if they had that crazy voicemail pick a number menu. I love the way she answered. She was at least somewhat friendly. She completely dropped the ball where it can which she did not even attempt to get to know you or get you to get you in the appointment book. But just because I’m feeling a little warm-hearted today I’m going to give her a D- because I think she’s trainable.

Dr. David Madow: Okay fair enough.

Dr. Richard Madow: Well there you have it. Our very very first video episode of the Dental Practice Fixers Podcast. It happens to be Episode 6, Season 2. But for those of you who are listening to audio only, we still love you just as much. If not more. So wherever you’re listening, go ahead and give us a five star. If you’re on YouTube give us a thumbs up, make some comments and we’re going to be back with another episode really soon. What do you say Dave? Where are you? Can you adjust that? I think the…

Dr. David Madow: What am I adjusting?

Dr. Richard Madow: The little fader or on channel 16 I think should be 15,000 mhz.

Dr. David Madow: Hold on, let me move that up.

Dr. Richard Madow: Perfect, you got it.

Dr. David Madow: Is that better? Does it sound a little better?

Dr. Richard Madow: Much much better, perfect.

Dr. David Madow: Hey guys until next time. I’m Dr. Dave.

Dr. Richard Madow: Dr. Rich. We’re the Madow Brothers.

Dr. David Madow: The Dental Practice Fixers. We fix all through your practice. See you next time.








If you enjoyed this podcast, check out our previous podcast, Dental Consultant Recommended Dropping Two PPOs and Now Practice is Declining

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