Do Dentistry, Not Time
Posted February 27, 2012 by Jennifer G
XLDent recently had the honor of sponsoring a seminar in Pella, Iowa featuring speaker Dr. Roy Shelburne. I had the pleasure of hearing his message for the first time in person. Everyone came away with some tools for improving their records and audit systems.
Just to give you a little background on Dr. Shelburne… he went to prison for 19 months for health care fraud. His story starts as one like most dentists, setting up his practice in the community he was raised in and successfully running it for 27 years. He spent much of his dental career serving others through the Virginia Dental Association, various Mission of Mercy projects, and dental mission trips. Then, in 2003 the Commonwealth of Virginia and the FBI began an investigation of him and his dental practice. Dr. Roy’s case was subsequently brought twice before a Grand Jury, and tried in U.S. District Court, where he was found guilty by a jury of Health Care Fraud, Racketeering, Money Laundering, and Structuring. He was sentenced to serve 24 months in Federal Prison and an additional 36 months of supervised probation. He has chosen to use his story as a lesson to all those dentists that could all-too-easily find themselves in his position, unable to defend their records.
The premise of Dr. Shelburne’s message is: “if it’s not in your clinical record, you didn’t see it, you didn’t say it, you didn’t hear it, you didn’t do it, it didn’t need to be done from a legal perspective.” If keeping detailed and concise clinical records because they reflect your clinical expertise and attention to detail isn’t enough reason to do so, then staying out of prison should be.
A huge lesson for anyone working in the dental office is a quote of Dr. Roy’s that started the day: “I was unwilling to plead guilty and go to prison. The errors were not intentional and I ignorantly believed this was an adequate defense. I learned ignorance is no excuse in the eyes of the law.” Rather than let his trials and tribulations extinguish him and his faith in the dental care system, Dr. Roy has turned his unfortunate circumstances into a tool to help other practices. His message has left me with a new outlook on the future and purpose of clinical electronic records. XLDent has always strived to focus its systems and tools on being patient-centric, working towards improvement in outcomes and providing clinical decision support. It wasn’t until I heard about the things found lacking in Dr. Roy’s records that I began to realize the important role software and the systems it can help implement are playing in protecting dental staff from going through anything like he went through. And maybe even a more important consideration is that clear, concise records support a more patient-centered care approach.
A good part of the talk was spent reviewing record keeping basics. I can’t go over every aspect here, but these are just a few of the important things that I left with a better understanding of:
- The Doctor is held to the highest level of responsibility for the accuracy of the chart, but every person in the dental office is and will be held accountable for what is/is not documented. The Dentists, Assistants, Hygienists, and Administrative Staff are all responsible for their role in coding, billing, and what is in (or not in) the record.
- Most often than not, a doctor or staff member doesn’t intentionally try to miss-code something or leave something out of the chart. Unfortunately, the law states that “No specific intent to defraud is required.”
- Record-keeping needs to be defensive… include what was seen, what was said, what was heard, what needed to be done, why it needed to be done, that it was done, and what occurred during that visit.
Suffice to say; in my 13 years involved with dental practice software support, implementation and sales, I have seen all too many records – paper and electronic – that are lacking in most of these areas. The good news is XLDent gives Doctors and Staff the tools to create the kind of bullet proof clinical records Dr. Roy lectures about. Of course, Doctors and Staff are ultimately responsible for what is in their clinical records, but the systems in XLDent are designed with efficiency, accountability, and accuracy in mind, providing a means to document completely. I hope this gives everyone a wake-up nudge to evaluate and improve the systems and records in their practices, if not only to protect themselves, but to also protect their patients.
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