Avoid Healthcare Fraud with Accurate Record Keeping

The Transcript

Art Wiederman, CPA: Hello everyone and welcome to another edition of the Art of Dental Finance and Management with Art Wiederman, CPA. I'm your host Art Wiederman. Welcome to my podcast. We're approaching. I think we're either at or over 150 episodes of the podcast and I'm very proud of the work we do here and today might be, and I know I've said this before, but it might be the most important episode of this series that I've done. And if you haven't heard of Dr. Roy Shelburne, you will today, and I will tell you his story when I go to introduce him.

But we're going to be talking about his story, which involves documentation in his dental practice in Virginia back in the early 2000s, and how he actually the feds came and called his number, and he actually spent 19 months in a federal prison camp in Kentucky. And the story is fascinating and the story is part of it. But what he does now to help dentists nationwide is even more important to make sure that you understand proper documentation and insurance coding. So we'll get to Dr. Shelburne in a minute.

I want to again encourage you to go on to the website of our partners Decisions in Dentistry Magazine, www.DecisionsinDentistry.com. Incredible clinical content on every possible dental clinical subject you can think of. They were there during the pandemic, and we're recording this in early March of 2022. So if you can believe it, dental offices when I'm recording today, next week will have been two years that they have shut down. So it's just remarkable in the dental profession, as it was in 2008, has been so resilient and so amazing and has come back and just done some great things and we're very proud of all of you out there. So Decisions in Dentistry magazine go to their website www.DecisionsinDentistry.com. I am a dental division director at the CPA firm of Eide Bailly that's Eide Bailly.

And I'm a proud member of the Academy of Dental CPAs. Twenty four CPA firms across the United States that represent over 10,000 dentists. We have been the financial first responders through this pandemic and I've been talking to you about PPP and ERTC and the HHS Provider Relief Fund and EIDL and any other letters I feel like making up that day. So, you know, if you're not working with a dental CPA, you should be. And again, my phone number is six five seven two seven nine three two four three and my email is awiederman@eidebailly.com.

Last thing I want to touch on because I do want to get to Dr. Shelburne, is if you had a greater than 50 percent reduction in your gross receipts in the second quarter of 2020, you are probably eligible for the Employee Retention Tax Credit. We have helped doctors for over 100 practices get over $4 million of tax credits. It is legal, it is legit and it's money the government's offering and we're going to go get some of it for you. If you had a greater than 20 percent reduction in any of the first three quarters of 2021 versus 2020, or a reduction of 20 percent in the fourth quarter of 2020 versus fourth quarter of 2019 20 percent. You're eligible for a much more wonderful, larger, vibrant, I don't know what other adjectives I can use credit. So give us a call and let us know.

OK, I want to get to Dr. Shelburne. Dr. Roy Shelburne is a speaker, consultant, writer and coach. He's a 1981 honor graduate from Virginia Commonwealth University School of Dentistry. After Dr. Shelburne graduated, he opened his practice in his grandfather's old hardware store. He'd served as president of the Southwest Virginia Dental Society and volunteer at Virginia's various MOM projects across the state. He has also served as a short term missionary to Honduras with Baptist Medical Missions International. So you're talking about a highly ethical, highly professional, a man who went to dental school like all of you to help people. So some dentists may fear, I'm reading this right off of his website, some dentists may fear litigation, but few worry about going to prison. So here you go, and I'm going to let him tell the whole story.

But on October 24th, 2003, the FBI broke down the back door of Dr. Shelburne's office and confiscated all of his business and dental records. Over the course of the next three years, every aspect of his life was subjected to the closest scrutiny. He was indicted in 2006, in October and in March of 2008, he was found guilty of health care fraud, racketeering and money laundering. And he spent 19 months incarcerated at the federal prison camp in Manchester, Kentucky, before he was released in 2010.

And during the investigation and trial, it became apparent that his records, billing and coding systems were faulty and that ignorance is no excuse. While incarcerated, Dr. Shelburne had ample time to reflect on his life and found that true release comes when we draw from our strengths, characters, vision, wisdom and experience. He's now a speaker and a consultant, one of the most sought after speakers in the United States, and we are going to let Dr. Shelburne tell a story today, as well as talk to you about what you should be doing in your dental office. Dr. Roy Shelburne welcome to the Art of Dental Finance and Management.

Dr. Roy Shelburne: Art, thank you for the invitation. I appreciate being invited to share. I'm passionate about being the last dental professional who goes to prison for things they didn't know or understand. So I'm not particularly proud of what I went through, but I certainly feel that what I learned is necessary to be able to share and thank you for inviting me to be able to do that today. Appreciate it.

Art Wiederman, CPA: Well, I give kudos to you for having the courage to tell your story on. I mean, hundreds of lectures that you've done podcasts, webinars and, you know, we are human beings. Things happen. You did not intentionally racketeer and do all these things. And again, we're going to get into this deeply. But before we do, I understand that you are a horseman and that you are a champion horseman as a matter of fact. Share a little bit about that.

Dr. Roy Shelburne: Yeah, I grew up on a farm, actually. Started by just riding ponies and horses and became involved in the quarter horse world. I became a world champion competitor, was actually placed at the World Championship Show Top 10 in the nation for about 11 years. It was great therapy for me. It was one of those things in the dental practice you're very confined in your view and you're focused on a very small area. Getting on a horse and just letting it all go with something that I really enjoyed and actually selling my horse after I was married, actually furnished our apartment when I went to dental school, so it not only is a hobby an avocation, but also helped me to finance my dental education as well as my first, my first apartment.

Art Wiederman, CPA: Well, you know, everybody's got to do it in a different way. Exciting for you. So, all right, I'll tell you what, I just want you to tell your story. Tell us what happened.

Dr. Roy Shelburne: Happy to. As you shared in the CV, I lived in the western part of Virginia. It was 2003. I've flown from Jonesboro, Virginia to San Francisco, California, to the American Dental Association meeting, and I was listening to Rudolph Giuliani, who was the keynote speaker that year. And I was in the audience so enthralled by what he was saying that when my phone began to vibrate, I didn't notice it. But the person next to me did. They elbowed me and said, Doc, Doc, I think your phone is vibrating and I pulled my phone out. In fact, it was, and it identified my wife as the caller. She was at home visiting my middle daughter at Virginia Tech at the time. So she wasn't home and knew I was at this meeting and could do the time differential and probably knew I was. I was involved. So I thought she did it unintentionally. I thought she may have butt dialed me.

So rather than answering it and disturbing that meeting, I closed my phone and Giuliani finished. The session was over and as everybody started to move out of that large auditorium, I called my wife. Phone connected and there was silence on the other end. Now, if you know my wife, she's usually at least two or three words into the sentence by the time the phone connects, she starts early and ends late. Great communicator. It was silent, so I said, Debbie, are you there? And she said, Roy, I am. Are you sitting down? Ever had a phone like that Art where you knew what was coming next was not going to be good?

Art Wiederman, CPA: Yes.

Dr. Roy Shelburne: I asked her, I said, Debbie, do I need to be sitting down? She said, Roy, you absolutely need to. And you know, in your mind, it starts to turn 90 miles an hour trying to figure out what I'm going to hear and what she shared with something I certainly would have never thought of in a million years I said, Debbie, what's up? She said Roy, James called. James, was our custodian at home, took care of the building. James called me to let me know that the FBI has come to your office. They've battered down your back door and taking all your records. Wow. Yeah, that was a punch knocked all the wind out of me, I took my deep breath and I tried to reassure her that things were going to be OK. It must have been some kind of mistake. Never, never really believing it would be so.

Talked with her for a while. Hung up the telephone. Now this auditorium that I was sitting in was almost empty at this point, and I was thinking, What am I going to do? The office? It was Friday. The office was closed. No team would be there. And I thought, Well, how about if I call my office just out of curiosity. Would there be an answer, and I called and after four rings, the phone was answered. Voice on the other end said, Hello. I said, Hello, who is this? Voice asked, Who's this? I said, I'm Dr. Shelburne. I own the office you're in and the phone you're talking on. What are you? Can you tell me what's going on? He introduced himself as an FBI agent and that I was a target of health care fraud investigation. He had executed a search warrant and they were gathering evidence to determine what their future actions would be.

And I asked him, I said, Do I need to be there? He said no. I said, Do I need an attorney? He said, I can't advise you. And I asked him, I said, What is this about? And his response was Doctor, you know what this is about. I said, Sir, I have no idea. Hung up the phone, went back to my hotel. That was probably 9:30 in the morning. Luckily, there was a seat open on a flight home, flew home to Virginia, got there about 9:00 p.m., drove past my office. It was surrounded by crime scene tape with multiple black FBI vehicles and I watched them carry boxes out of my office into those vehicles.

Called my team. I asked if anybody knew what was going on. They didn't. Went to church the next day, asked for their support. Went to the office on Monday, never expecting any of our patients to come because the search and seizure happened the weekend our fall festival occurred, so there were parades through town. There were booths set up on the side of the streets. And guess what the topic of conversation was - me. Our practice was in the largest town in the county that was 1,800 one eight zero zero. Population of the county is about 20,000. Very, very rural. Everybody knows everybody else.

But I was surprised a lot of the times as we went through the process that the relationship I developed with my patients superseded anything that was happening on the inside, any allegations otherwise. So we remained very busy all during that period. Investigated for a course of three years. During the investigation, probably two years in, three teams of officers went to my three children's universities. They went to the bursar's office, they got the schedule of my children. Went to campus police so the police could direct them to my children's classrooms. They knocked at the door, came into the classroom, flashed their FBI insignia, pulled my children out of their classroom. Amongst their classmates, took them to a separate, empty classroom and interrogated them anywhere from 45 minutes to an hour and a half.

So no stone was left unturned through the process. They knew more about me than I did. They subpoenaed records from my bank, from the companies I did business with. Henry Shine had to give them my invoices. There was. There was no component of my life that had not been investigated. Three years and four days after the search and seizure, the officer that I talked to on the telephone came to my back door, knocked on the door, came to the door. He indicated, he said, Dr. Shelburne, I'm here to arrest you.

He came with seven other FBI vehicle or seven other officers, four vehicles altogether. Three flatbed car haulers. Was escorted to my kitchen, was handcuffed with a chain around my waist attached to the handcuffs so I couldn't raise or lower my hands any more than three or four inches. Had leg irons on. The phone began to ring, he was reading me my rights, my wife was on my left shoulder with a right hand on my shoulder. Phone began to ring and she turned to answer it. And the officer said, I can't let you answer the telephone. We can't let anything interrupt these proceedings.

So she turned back around, answering machine picked up after six rings and my daughter, you could hear the recording. She was obviously very distraught. She was crying, but she said, Mom, dad, they're here. They're taking my car. I don't need my car. What's going on at home?

Because I was charged with racketeering and money laundering, it allowed the government to confiscate everything I owned at that point and anything I help helped to pay for.

Art Wiederman, CPA: So which included your children’s cars and assets or whatever? So can I just for a second? I just want to understand. So for three years, you continued to practice dentistry. Right? I did. And I'm assuming at points they asked you for information. Did they talk to you? Did you? When did you find out what? What? When? And maybe I'm getting ahead of the story. But when did you find out what? Oh, what was the cause of all this?

Dr. Roy Shelburne: Well, to be honest with you, there's a whistleblower statute. A person can make a complaint to the fraud division, which someone did, but that person or persons are protected. So you're it's never to disclose who they are. So as far as the course of. The action complaint to the FBI, then they did an evaluation of our submissions to the insurance card. It was a Medicaid issue to Medicaid and we were the poorest, or next to poorest county in the state of Virginia. So if you were 18 or under, there was a 95 percent chance that you were covered with Medicaid. Ninety five percent of the people that live there and those were my neighbors' children, those were my friends. My kids went to school with them. So we felt it was something that we needed to provide care for the indigent.

So we had a very significant Medicaid practice and actually they did an evaluation of those submissions for six years and over the six years, six years that they evaluated, we were paid three and a half million dollars during that period, which is a large amount of money. That's about $500,000 a year. A half a million dollars. It was a jury trial. The jury's never made known the amount. They only determine guilt or innocence, and of the three and a half million dollars that we got over the six year period. Do you know the amount that I got that I wasn't entitled to? We did make errors and we got money that we weren't entitled to.

Art Wiederman, CPA: I did. I always research before I have a wonderful guest like yourself on. I do know the number, but why don't you go ahead and share what? So out of three and a half million, how much were they was in question?

Dr. Roy Shelburne: Seventeen thousand eight hundred ninety nine dollars and fifty seven cents. That's less than one tenth of a percent. And I thought that was a pretty decent error percentage. One of the things I didn't understand Art, you know, you talked about intention to defraud, intent. Intent from a legal standpoint, of course, would include if you submitted a claim for a patient you never saw for a service, you never did, that's blatant intent, and I never did that. There was no allegations that I did that. But what I didn't understand the definition of intent to defraud from a legal standpoint, it includes blind disregard, which means if you make similar mistakes in not having a system in place to be able to identify and correct those errors, that is considered blind disregard and intent to defraud.

So I didn't have systems to identify and correct those areas. We did make some. We did get monies we weren't entitled to. Of the seventeen thousand eight hundred ninety nine dollars, we also did our own investigation, inquiry and audit for that six year period. We went back through those records and there were, of course, treatment that we provided should have billed for and could have billed for. That was about $30,000, about not quite twice what they found that we got that we weren't entitled to. That made no difference.

Art Wiederman, CPA: So, theoretically, you were $13,000 that you were technically owed. But they still came and got you.

Dr. Roy Shelburne: They still came and got me, yeah. You know, the from the review of our submissions and we were paid a lot of money during that time. Then they did. They sent letters to 15 of our patients and did a screening in a classroom on a weekend. And that triggered this search and seizure. And after the search and seizure, they had a lot invested. There was nothing that was going to stop that. They actually they contacted Medicaid to ask them, conduct audits. It was Durell Dental who's now DentaQuest, the administrator of Virginia Medicaid, and they did a first audit and the patients that pulled it was at random. There was no common thread between them and it came back clean.

And the government said, No, you don't understand. He's been charged with this, this and this. We want you to do a more in-depth review. And they did a review of the 15 patients during that six year period that we were paid the most money up from highest reimbursed to the 15th highest, and they did an evaluation on that. And I share the facts when I'm presenting the conversation between Durell Dental, DentaQuest to the Virginia Medicaid. They basically said We don't see anything that he's done that we don't see in any of the other markets. We don't have a problem with Dr. Shelburne. And I thought that would have stopped it from the Medicaid audit point of view. But the government's response was, well, you just don't have the ability to go as deeply as we've done to determine he's committing health care fraud.

Art Wiederman, CPA: And this is about $17,000.

Dr. Roy Shelburne: This is about $15,000.

Art Wiederman, CPA: So they arrest you and then are, are you? I mean, I'm assuming that you were out on bail during this trial or did they keep you in prison? What did they do?

Dr. Roy Shelburne: That's another interesting story. So I was arrested. I was transferred to Bristol, Virginia, where I spent the night in jail. They kept me in in solitary confinement. Transported to the courtroom, walked in. My attorney was on the left. I sat down next to him and he said, Doctor, I got good news and I've got bad news. And I said, What's the good news? He said the good news is that I've agreed we've come to an agreement with the prosecution on the terms of bail and you will be going home. And I said, Well, that is good news. What's the bad news? He said the bad news is for them to agree, you're going to have to surrender your license to practice. So my life evaporated in that moment.

But there were there were so many providential things that happened. And this was one of those days. So the judge comes in, we stand, sit, he looks at the prosecutor and asked him what I'm being charged with. And the prosecutor shared the charges and then it got to the point of bail, and he asked the prosecutor, Have you come to an agreement in terms of bail and the prosecutor says yes. And he said, Well, what are those terms? And he said, Well, Doctor Shelburne, when we asked that he post this amount of money and we've asked that he surrender his license.

So in almost every case, the judge would then look at me and my attorney and say, Are there any objections? And we would have said no, because that was the bargain that they had set. He didn't do that. He looked at the prosecutor and asked, Does the Board of Dentistry of Virginia still exist, sir? And the prosecutor goes, Yes. The judge asked the prosecutor, is the board aware of the situation? And the prosecutor said yes. The prosecution had tried to encourage the board to act on my license and revoke it. They hadn't. So the judge looked at the prosecutor and said, Sir, do you are you asking me to supersede the power of another governmental agency who has the responsibility of determining whether or not individuals can practice appropriately in Virginia? You're asking me to do that? And the prosecutor looked at the judge and said I guess.

The judge said until the board acts on this man's license, he can he can practice dentistry. But in this case, it went everywhere. I have a friend who practices in New Jersey. I was the story in the New York Times. Whoo hoo. I made it to the big time. So I thought without a doubt that my practice would be over. I was wrong. The best term I ever had financially was the year after I was indicted and the year before I was prosecuted. So you know how you'll diagnose treatment for patients, either a bridge or partial, and they would be in my chair and I'd go there again. You know, they delay it for whatever reason and I Miss Smith, you really need this crown and they would be lying in the chair and they would go, Yeah, I know I do, and I really want you to do it. And they would roll back to look at me and say, But I don't know if you're going to be here or not, so do it now.

Art Wiederman, CPA: Oh my God. So, that's so that's kind of a I shouldn't joke about this, but I mean that that's one way to grow your practice is to say you might be going to jail, let's get it done now. My God.

Dr. Roy Shelburne: They say any publicity is good publicity. In this case, it was. I wouldn't recommend that you get it that way, but the practice actually grew and became even more successful after that. You know, take home to the listeners, have that relationship with the patients. They know who you are, they trust you. And anything that's coming from the outside can have little effect on what happens from that. So nine day trial. Learned a lot in the process. There were 118 instances Art that were brought and the jury had to find me guilty on one of those 119 instances. So they had 119 chances to find me guilty. And we prepared directly for those 119 allegations.

What I didn't understand the first probably third to almost half of the trial hinged around our lifestyle, the vehicles that we drove, the vacations that we went on, and as I shared, the jury never knows the amount. So in their mind they were, they were expanding it so this must have been a huge amount of money and the motive that the government established that I had for committing the health care fraud was to fund my lavish lifestyle. How you do that with $17,000 over the course of six and a half years, I don't know. But that was my motive.

And like I said, the first four days were establishing, I was the rich dentist and to be honest with you, we did very extensive care for our patients. And as a juror, from their point of view, they're taxpayers, they are paying money to fund the Medicare Medicaid world. They're working. They may not even be able to afford to take their children to the dentist. There is this dentist providing Cadillac care, treating baby teeth. And why in the world would you treat a baby tooth? You know they're going to lose it, why in the world would you? You know, I had patients. We would present a treatment plan. It was a primary tooth that needed to be restored, and they would look at me and go, Dr. Shelburne, that's a baby tooth. Why would you even treat that? Go ahead they're going to lose it anyway, take it out.

But if the tooth could be restored to be able to maintain the space for that, that child and give it something to chew with, I would restore it with stainless steel crown any day of the week. And you know, the jurors are looking at that and go. He got paid this amount of money to be able to restore that. And I can't go. So why in the world would I feel that it's important to do that? He made money to fund his vacation to wherever. And you know, I can't even take my kids to the dentist and they're using my taxpayer money to do that. So, you know, getting behind the curtain and thinking the way they think, it's a hard way to defend.

Art Wiederman, CPA: It's a remarkable story, and again, Dr. Shelburne, it's not like you went into your career to start defrauding people and insurance companies. You went in as an honest dental professional like most of the 200,000 dentists in this country are. And this is what happened. So you went to prison and I mean, we could spend, I would love to spend two hours hearing every nook and cranny of the story. Unfortunately, I don't have the time, but so you went to prison and then that gave you an opportunity to kind of start thinking about the next chapter of your life. You were sentenced for what it was two years, right?

Dr. Roy Shelburne: Twenty four months. Yes.

Art Wiederman, CPA: And you served 19 of those months. You must have you got out on good behavior or time served or.

Dr. Roy Shelburne: Yeah. In the federal prison system, the best amount of reduction you can get for good behavior 15 percent. So 19 months in federal prison, two months in a halfway house and then was released on three years probation after that. I to be honest with you, I'm here today and I've been able to be given a platform because people have supported me. Most people, if you've been in dentistry for any length of time at all, you know, Linda Miles.

Art Wiederman, CPA: Oh, Linda's a dear friend. I love Linda, one of the finest people in the dental profession. Just as she's been on our podcast, she's. I love Linda.

Dr. Roy Shelburne: So if you know, Linda, you know, she's all about making sure she takes care of people, was a friend of hers as well. She's a Virginian and I'm a Virginian. The month before I was to submit myself to the federal prison camp for incarceration, she called me and she said, These are her words, Roy, you're going to be a speaker. I said, Linda, thank you for that. But that's not going to happen. You understand where I'm going and what I've been through. She goes, I absolutely do. But you have a future. You have a story that needs to be told.

So I didn't know that she had an organization called the Speaking Consulting Network that teaches people who would like to be speakers, writers and consultants in the dental world how to do it. And she arranged for me to attend the next meeting after I was released from the custody of federal prisons, and it actually occurred the day after I was released. Her meeting was in Anaheim, California. She arranged for me to fly to Anaheim to that meeting the day after I was released from custody and learned how to be able to manage that business, how to be able to move forward, especially when you have a platform that you need to share.

And literally, the day after I was released, she and that organization gave my life back to me. So Linda has retired. She sold the business to Lois Banta now, but it still is existing and still vibrant. So if you have any listeners who might be interested in a speaking, writing and consulting career in dentistry, that's the meeting that you need to go to be able to learn how to do that.

Art Wiederman, CPA: No. And Lois is also one of the iconic people in dentistry. So what you're saying is while you were in prison, you didn't have any inkling of that you know, what's the next step in my life? I mean, you. Did you actually? You lost? Did you end up losing your dental license in the state of Virginia?

Dr. Roy Shelburne: I did. In Virginia, the minimum period of revocations three years. So the entire board has to meet and act on a dentist license to revoke it. That can suspend, but they can't revoke. And I knew as a result of the conviction I would be looking at a revocation. So doing the math, that board meeting where they all come together to act on my license wouldn't occur until after I was incarcerated. I had to be present for them to act on it. So it would have meant that after I was released from prison, they would have acted on my license and revoked it. But the three year revocation period would start then. So did the calculation. I voluntarily surrendered it for revocation prior to going in prison, which started the clock ticking prior to the two years incarceration.

I was able to reapply. The three year period was July the 11th of 2011. Had done about 600 hours of CE in the three years my license was revoked. After being released, I went to Virginia Commonwealth University, Virginia's dental school and I rotated through the different departments and they could observe my ability to be able to provide appropriate care. They provide a letter of support to the Board of Dentistry. For the dentists on the podcast, I took my boards over again. That was kind of fun the second time, passed them.

Art Wiederman, CPA: That's impressive. There's no way. How many years had you been out of dental school?

Dr. Roy Shelburne: When I when I retook it, thirty one.

Art Wiederman, CPA: Yeah, there's no way in you know what that I could pass the CPA exam again.

Dr. Roy Shelburne: You're probably selling yourself short. You could probably do that, right? Ultimately, I did that, passed them. Gave the board all that information. They met on December 1st of 2011. The Commonwealth attorney vehemently opposed the reinstatement of my license. Was passionate in her argument that I should never be given my license back. I was asked to leave that room where they deliberated. I was out of the room for about an hour and 45 minutes. They called me back in, the board chairman stood, said Dr. Shelburne, we had a hard time with this. We talked for a while, we argued for a while and we actually yelled a little bit. But we have come to a consensus. We have agreed to give your license back to practice dentistry.

I was shocked. I, you know, most things are online. I had gone back to find out if anybody who had had their license revoked would have ever been given it back. So I didn't have a whole lot of hope that I would. But I thought if I if I don't, at least try, I'll never. I'll never be satisfied. I'll never let it go. So I was shocked. And coincidentally, the American Dental Association, I surrendered my license for revocation. I was at the federal prison camp in Manchester, Kentucky, got my renewal letter from the Virginia Dental Association with my dues. And Terry Dickinson, dear friend of mine, was the director of the Virginia Dental Association at that time. And I wrote a letter back. I said, Terry, I'm sorry, I won't be able to renew. You know where I am. He actually wrote a letter of support to the judge, asking the judge to be lenient in the sentencing. So I wrote the letter back and I got the nicest letter back from Terry. He said, Doc, if and until you can, you can support yourself and be able to keep your license active. We will consider this a hardship case in your life. Your membership in the Southwest Virginia Dental Association, the Virginia Dental Association and the ADA will remain intact.

Art Wiederman, CPA: An absolute remarkable story. So, Dr. Shelburne, I want to. I want to. I want to turn for a second and I want to use the rest of this time to help our listeners because obviously, you learned a lot of very, very difficult lessons through what happened to you. It was, you know, out of three and a half million dollars to be, you know, prosecuted and harassed the way you were over $17,000 of which most of which was probably wasn't even an issue. You know, it just shows you the power of the federal government and it shows you, folks. You know, if you're not reporting income, the IRS has the same power that the federal folks have that took down Dr. Shelburne.

So let's get into now what you've been doing the last, you know, 10 years or so, which is helping dentists all over the country and probably all over the world. Let's start talking about Medicaid. One of the issues that they came after you for was medical necessity in the clinical records, right? And that's a big part of what you talked about. So talk about that. Talk about what, you know, one of your biggest mistakes that you talked about on your website and in your lectures that I've heard you lecture before is that, you know, you didn't pay as much attention as maybe you should have. And I'm going to tell you that there's thousands of dentists listening to this podcast right now, nodding their heads and go, Yeah, that's me. I don't I don't pay attention as much as I should. I trust Susie at the front desk to make sure that insurance is built right and that we document, and that the hygienist and the blah blah blah blah blah. So talk about the medical necessity part of what got you in trouble and what people should be doing. And I also want to give out your information here shortly as far as how you can help people. But let's start with the medical necessity part.

Dr. Roy Shelburne: Sure. Art, thanks for the question. If it's not in your clinical record, you didn't see it, you didn't say it, it wasn't done, it didn't need to be done. It does not exist from a legal perspective, so that clinical record could testify for you very loudly and strongly and support the medical necessity for the treatment that you've provided. Anything that you provide treatment for needs to be established in the clinical record, what the diagnosis is and if you're on the medical side, all reimbursement is generated from the diagnosis. We're kind of backwards in dentistry. It's the treatment we provide that is reimbursed. And the diagnosis, of course, should in a perfect world happened prior to. But it doesn't.

For example, justification for scaling and root planing. A complete periodontal diagnosis has three variables to be as thorough to substantiate that treatment. And those variables are it's either mild, moderate, severe, it's either generalized or localized, or it's chronic or acute periodontal disease and or inflammation. Gingivitis or complete periodontal diagnosis would be severe generalized chronic periodontal disease. That's a diagnosis. I almost never see that in a clinical record. I see evidence that there is periodontal disease with either the radiographs and or the periodontal probing, but I almost never see a diagnosis. How can you treat something that you have not diagnosed and recorded prior to?

You can treat it, but what's the substantiation, the need for? So for the scaling and replaning or periodontal treatment, you need to have bleeding on probing. You have to have bone loss 10 percent or greater and or probing depth of five, four five or greater, depending on what the plan substantiates. That supports the fact and helps to drive that diagnosis of the periodontal disease. And if you'll look at the coding, it is changing, the code maintenance committee actually will meet day after tomorrow. I'm flying to Chicago, sit through that meeting to listen to the submissions request for coding changes, to understand the motivation behind it and to know what the new codes are going to be in 2023.

But if you're looking at the 4346, that code actually describes and contains in its descriptor a diagnosis. It is scaling in the presence of generalized, which is 30 percent of the mouth or greater moderate to severe inflammation. So to treat that with a 4346 a scaling, that clinical record should establish the fact that the inflammation is chronic and either moderate or severe. So that helps better to understand that there is a diagnosis that is necessary prior to providing the treatment.

And to be very specific, there was an issue with a simple, restorative procedure. I think it was a OF lesion on tooth number 19. And radiograph was taken, but it was the lesion was not evident on the radiograph. So the argument was by the government was I treated a tooth that the radiograph did not show evidence and they had an expert witness, a dentist who said, in their opinion, if the lesion didn't show up on a radiograph, it would not warrant treatment. And usually when I say that, we'll get a groan from the people that are there because we in dentistry understand that not everything is evident on a radiograph, but do our patients understand that if we're going to treat something, even though we've taken an radiograph that it may not show up on the radiograph.

They know you should it's black and white. It should show up on a radiograph. You treat it, or if it doesn't, you shouldn't. So the point was I treated a tooth that from the radiographic evidence, would not indicate that the tooth needed to be treated. So supportive information and documentation for that would be a notation from the doctor and or a photograph. So anytime something happens during the course of treatment that surprises you, doctor, that is that should trigger the bell in your head to go. I didn't see that. I'm surprised.

And by the way, therefore, anybody else who follows me who might audit me or look at what I provided, they're probably going to be surprised too. So this is time for me to stand up, step back and have my assistant take a photo of what's going on, because the picture sometimes is worth a thousand words. And if you're surprised and you see something that does surprise you, that's a way to document that in a way that it would help substantiate what you did to take that well, you treated a tooth that didn't need to be treated because I didn't see anything in your clinical record that would suggest it needs to be treated. It would take that off the table. So there are all kinds of issues that I was unaware of. You know, for me, I'm the dentist. I have an education. Don't you trust me? The answer to that is, no, I do not.

Art Wiederman, CPA: So. So in this particular situation, you didn't see it on the radiograph, right? Correct. So the proper thing to do, which apparently maybe you didn't do, is to have the assistant take an intraoral photo or some sort of additional documentation so that three years later, when you're in a court of law like you were, you could say this is why I recommended this treatment on this tooth. Right? I mean, it's pretty straightforward, right?

Dr. Roy Shelburne: It's very straightforward. You know, we don't live in a world where your clinical decision based on what you see, that nobody else can see, that will not help you, that will not support you, because it's not something that is empirical. Somebody can look at and go, I see what you saw. If you don't take a photograph, they didn't see what you saw.

Art Wiederman, CPA: So that would be considered the standard of care. I would think.

Dr. Roy Shelburne: Documentation.

Art Wiederman, CPA: So you've been in hundreds, maybe a couple of thousand. I don't know how many dental offices you've been to consult with people and dentists you're talking to every day. On a scale of one to 10 how is the dental profession doing in medical necessity documentation?

Dr. Roy Shelburne: Um, probably 10 percent of them do what I would consider an excellent job. And in most instances, that 10 percent the reason why they do is they probably have had an issue with a carrier, either an audit or something else that has made them aware of what's going on. And Art, I think it's important to share the world today audits. Audits, they say they occur randomly. They don't. All insurance companies actually share their submissions data with a company they call called PNO Strategies. They put together this bell curve of averages. Doctor averages in the middle of that bell curve, and more than likely audits don't occur with them. But the further you go out to the right standard deviations one, two or three, the more different you are than other practices and the more likely you're going to be audited.

And what happens in an audit, for example. Here's a here's a real case, a doctor was going to do a crown on an upper left molar, sent a PA to substantiate the need for that crown on the molar, the x ray that they sent in did not meet standard of care. It was not a good x ray and the individual who looked at that, the doctor who looked at that, the consultant looked at the X-ray and thought, Hmm, if they think this is diagnostic, if I go back through and do a little bit audit of the radiographs, I wonder what I'm going to find because a non diagnostic radiograph is a worthless service. Wonder if number one, if they're charging for them and number two, how many do they do?

So this dentist was audited. They pulled charts for 20 patients, reviewed the radiographs. For those 20, found out that 22 percent of the radiographs they billed for were non diagnostic. They used that 22 percent. They looked back six years and they multiply the 22 percent by every x ray they paid to that doctor over that six year period. And the number this doctor had to pay back to the insurance company was almost six figures. It was seventy eight thousand dollars.

Art Wiederman, CPA: But I mean, how scary is that now? Let me throw something out and then I want I want you to talk a little bit about what you do to help the dental profession. And what you've done. I mean, you've probably saved hundreds, if not thousands, of dentists from going through potentially what you go through.

But so let's say we have a dentist who is doing things. Of course, that's none of my listeners, right folks, you all do everything by the book, the way Dr. Shelburne teaches it now, right? But you know, you have a doctor who just, you know, I mean, burns the candle at both ends and maybe cuts corners and well, we can do this and they don't document. So you ended up getting the knock on the door, the door knocked down, because somebody who you never found out who it was, turned you in right? If you doctors are doing things in your practice, whether it's financially or clinically, that you shouldn't be doing, your dental team knows, isn't that right, doctor?

Dr. Roy Shelburne: Yes. And the scary part is the individual who makes the complaint can get up to a third of what is recouped. So are there financial gains for those people who do blow the whistle? So if you have that disgruntled employee and you're doing things that are funky, do they have a lot of potentially dangerous information that they can share and actually gain from not only their satisfaction, but financially. It's scary.

Art Wiederman, CPA: Wow. Take a second, Dr. Shelburne again. I wish I had more time to talk to you today, but I want you to talk about you not only or a nationally recognized speaker lecturer. You go to dental meetings all over the country. You've been on one or two podcasts, I suspect. And but what do you also consult with dentists in their offices to help them with these issues. We're going to talk a little bit about billing codes before we finish up here. Talk about what you do, how you can help someone and how people can get a hold of you.

Dr. Roy Shelburne: Thanks. If you google me, I have a website or if you, my website is just my name, www.RoyShelburne.com. I help offices. I audit to be able to give them not only areas that are put them in danger, but I almost always find things that they are doing and they're leaving on the table that should be reimbursed for. So it goes both ways.

Art Wiederman, CPA: Get into that in a second.

Dr. Roy Shelburne: Yeah, I want them to get every single penny that they are entitled to legitimately and underline and stress legitimately. There are all kinds of things that you can implement in your office that will increase, but I want to keep you out of harm's way. One of the things I do is help them adopt a seven-step compliance program, which takes the blind disregard off the table. They'll do audits on their own occasionally to make sure that they're doing it correctly, not leaving anything off on the table, but also getting everything that they're entitled to.

So help them implement that, help them with their documentation templates as far as that goes, to make sure that they capture everything that they need to. Training the team to be able to help support the doctor in that way. I'm a proponent of having everything delegated to the individual who will allow the doctor provide their highest, best use, which is at the chair, either educating the patient and or providing care, not doing the documentation.

Art Wiederman, CPA: So, so how can folks get a hold of you and how do you work with folks and stuff?

Dr. Roy Shelburne: Sure. As far as I can either help them with the audits and the implementation, the consulting piece, I can do as much or as little as they care for me to. So they can either email me, which is my name again, RoyShelburne@gmail.com.

Art Wiederman, CPA: And folks, that's SHELBURNE.

Dr. Roy Shelburne: Correct. And I do kind of an assessment prior to make recommendations in terms where I am and I want to be able to give them the biggest bang for the buck. So number one, highest risk. Number two, which will increase the reimbursement and keep them off the radar with those companies who kind of take a look at what we do and why we're doing it.

Art Wiederman, CPA: And doctors, I want to make a comment because I've done something very, very, very difficult for me and my podcast. I've stayed quiet most of the time because this gentleman has an amazing story to tell, and I wanted him to tell it without any commercial interruptions. But I want to again stress, and I'm actually going to be recording a podcast, a very interesting one shortly, which we're going to talk about leadership and ethics, but everything that you do to your employees needs to bleed of we are doing everything by the book. It is not about the money. It is about what is best for the patient. And part of that is your documentation, because obviously Dr. Shelburne was victimized by, you know, maybe him not watching it as much as he should. He learned the lesson. He, you know, he paid the price, but he is paying it back big time.

So if you are not thinking that, maybe you know you're not doing things right, you might want to give him a call. But folks, you must act with honesty, integrity and transparency in your practice. Or else you could have an employee who's got the goods on you and you just don't want to do that. So I want to get a little bit Dr. Shelburne into, you know, billing codes. You said that lots of dentists leave money on the table. So and we had a we've had a couple of podcasts on the subject. But what are the biggest mistakes that you see the dentist making using like the wrong billing codes, maybe give some examples and maybe some gems here?

Dr. Roy Shelburne: Sure. Well, for example, you're obligated to use the code that best describes the service that you're providing. I see people play a little bit with a coding. OK, this doesn't get paid, but this is kind of like what we're doing. But so let's use that code. No, use the code that best describes the service you provide. And period. Well, for example, if you're doing a crown and the insurance company is going to you did a porcelain fuse to base metal crown, but you bill for and all porcelain crown. Ultimately, did you provide a crown? Yes, but all crown codes are not alike, they actually describe different type of materials that we used to provide that crown. So the reimbursement for a porcelain fused to base metal crown is less than the porcelain crown. So if you bill for the porcelain crown, you may have gotten money that you aren't entitled to and that would be considered a fraudulent submission.

You need to make sure that when you're choosing your codes, you choose the code that best describes the service you provided the patient. An example of codes that patients or that offices may not be aware of as far as during the prophy. If you are also putting the denture in an ultrasonic, there's a code that you can bill in addition to for cleaning the prosthesis as well as prophy of the patient's mouth. A lot of offices I know don't know about that code.

Another one is an evaluation code. The 180 is evaluation, with the patient, it's a comprehensive periodontal evaluation. And some people think, well, that's only a code that a periodontist can use. No. That code can be used to describe any situation where a patient has periodontal disease or is at higher risk of periodontal disease. And the only stipulation over and above the 150 and the 120 with a 180 is that it mandates a periodontal evaluation and charting. So if you're doing that anyway, ask for the D180. If you don't ask for it, you're not going to get it. It's going to be reimbursed at a higher rate generally than the 120. So like I said, if you don't ask it, you don't get it and some insurance companies will not recognize it, if that's the case, ask for the alternate benefit of the 120. So it's a matter of using the correct coding in a way that is considered acceptable and then using other techniques to be able to make sure that you don't drop it, that you don't leave it on the table.

Art Wiederman, CPA: So, so I have a situation came out interesting. I want to get your take on. So dentist is contracted with an insurance company in a PPO, and the PPO allows for a, let's just say, a porcelain fused to metal crown. And the fee is $800, right? So the doctor looks and says, No, I don't think that's the best restoration. I want to do a cubic zirconium crown or I want to do a gold crown or something that is more expensive. And the doctor then goes to the patient and says, you're going to sign a consent to allow me to charge you the higher fee, and we're only going to bill the insurance what they pay for. Is that OK?

Dr. Roy Shelburne: The answer is maybe. No, it is not always, it depends on the plan. So it's a great question, Art, I get this all the time and this is something that I teach. Absolutely. So number one, you need to contact the plan to find out what their position is on what's called optional services. That's what you've described. Optional service. They're upgrading the service to the patient. Patient needs to be made aware if the insurance company does recognize the patient needs to be aware. They sign a document that says, Understand I'm getting updated or upgraded treatment. I do agree to paying the difference that needs to be attached to the claim to the insurance company, so they're made aware of the discount and then deal with the upgrade. And can you collect from the patient? Yes, it's not 100 per cent of the time.

It also depends on the services that you're providing some services. They will let you upgrade other services they will not. So it's a moving target. One insurance company may allow. Another company may not at all. Some will restrict it. So it's kind of all over the board you need to. Ignorance is no excuse here as well. You need to understand your limitations and be able to abide by those limitations. In your example, can you? Maybe.

Art Wiederman, CPA: So if the insured so you could go and do all of this and then the patient agrees, yes, I'll pay the $1,500. And the insurance company pays half of the 800 and the patient basically pays 1100, but that could still not be legal. I don't know. I'm not a lawyer, but legal or allowed because of the insurance company says, No, you cannot upgrade. I mean, but then isn't the insurance company dictating treatment?

Dr. Roy Shelburne: They are not dictating treatment. They're dictating what they're going to pay for. So they do not say, Doctor, if you can't do that, they say Doctor, if you do that, I'm not going to allow you to do this or pay for it. Whatever the limitation is on the plan.

Art Wiederman, CPA: So could they could they say if you're going to do the $1500 crown, we're not going to approve anything for that particular tooth?

Dr. Roy Shelburne: They could possibly if it's a replacement, yes, OK. But then the limitation period, they could say, no, we're not going to pay for it. And by the way, you can't bill the patient.

Art Wiederman, CPA: But it's all about documentation and. Exactly. So you know what? So let's talk about the people listening to this podcast. I have thousands of listeners and they're listening, they're going, Oh crap. I've been in practice for 30 years and I don't document this way. I don't. And my assistants don't document in the charts in my, you know, my front office does. What if we've been doing stuff wrong forever? I mean, is it too late? What do we do if they if they listen to us and say, Oh my goodness, I maybe I really need to take a look at this. How does that work?

Dr. Roy Shelburne: Yeah, it's never too late. You know woulda coulda shoulda. I wouldn't go back and disclose anything, but I would. I would develop a journal. And, like I said, the audit plan that I suggested you would document just as if it were a meeting of the Rotary Club or whatever it is on X on date, we initiated audit program. In our practice. This is what we saw. This is what we have now implemented to make sure moving forward that doesn't occur anymore.

And if there's a policy change, for example, if you do implement the optional service, you need to outline that, have everybody in the office read and understand that and sign it so they know what you're doing and why you're doing it and just adhere to anything anytime you make a change or notification. There again, it's important to document in a way that if you do get audited, the company comes in and goes notices you've done something funky and they may initiate an action. And they may want to know what have you done in lieu of what we found to be able to do that? And if you have that history where you implemented that program, you could say, Yes, we did notice that we did this incorrectly, but this is what we have implemented moving forward. So in that scenario, you might be liable to reimburse money going past, but they're not going to take action against you now because you did what was reasonable to correct and to become more compliant moving forward. The blind disregard is basically taken off the table.

Art Wiederman, CPA: They don't teach this in dental schools, and I'm assuming there's a lot of this stuff that's going on. And at the end of the day, Dr. Again, I am a broken record. It is about acting with honesty, integrity and what's in the best interest of your patient and document Doc. I mean, it's the same thing in my world. You know, I tell you, I've taught young accountants for 38 years that I need to be able to read your work papers. And three years from now, if I'm sitting in front of the IRS, a government agency just like the one that came after you.

I need to be able to say this is where I came up with my numbers and this is how we did it. And there's black, there's white and there's gray, and it's probably the same in the world of dentistry. You know what we do all day long black. We don't even talk about being totally illegal and gray. You know, we have to talk about it and think about it. Is it in the best interest of the patient? Is that a good way to look at it?

Dr. Roy Shelburne: Oh, absolutely. You know, there are some areas of gray, but it's not gray because it hasn't been established. It's gray because we in dentistry are subjective. So if I gave the same clinical records for one patient to five different dentists, how many different and distinct treatment plans would be provided? Five? Oh, probably seven or eight, because on one you do two or three. Right?

So if you substantiate and document appropriately and when a reasonable human being, although they would not have done it that way themselves, they understand from a dental standpoint, it may be a treatment option. You know, their philosophy is to do it this way, but not that way, even if it is shades of gray. There are ways to document it in a way where a reasonable mind would go. I may not agree, but it makes sense to me that they did it this way, and I know some other people that do.

Art Wiederman, CPA: Dr. Shelburne, we're pretty much at the end of the time I have. Anything else you want to share with our audience about what you've seen, what you do, what they should know. We've talked about coding. We've talked about medical necessity. What else? Anything else?

Dr. Roy Shelburne: As you said, be. Your goal should be to number one provide the best care for your patients. Number two, to educate your team so that they understand what you are trying to accomplish in your practice and lead in a way that is congruent with what you say you are. Because team members are like children, they can look at you and they know what's going on behind. And if you want to have team members that will stay, will support you, will help you move forward, make them a part of the practice. Give them a voice and listen to them.

Art Wiederman, CPA: And when those patients doctors are asking when you walk out of the room or asking the hygienist or asking the assistant or asking the person at the front desk, Do I really need three crowns? You need those people to basically say, Mrs. Smith, if Dr. Shelburne diagnosed that procedure, then you need it because he does not diagnose anything that is unnecessary and that is not going to help you with your total health. If they're saying anything less than that, folks. Not good.

So, Dr. Roy, Shelburne, you are a gift to the dental profession. You paid the ultimate price in this life. You went to prison for something that you know was you thought you were doing right, but you weren't. And what you're doing is you're paying it back to your profession. So your legacy. My friend Gary Takacs has taught me about legacy. So your legacy is helping thousands of dentists, hopefully to avoid in any way, shape or form what happened to you. Would that be accurate?

Dr. Roy Shelburne: Yes. Thank you so much. I appreciate that.

Art Wiederman, CPA: And lastly, I think one more time to give out your contact information. If anybody, if you guys are thinking you need some help or some consultation. I'm assuming Dr. Shelburne. Also, your lecture schedule is on your website so people can find out if you're going to be in their town. If Dr. Shelburne is in your town and he's speaking or he's on a webinar, listen to what he says because he's going to do a much deeper dive than we were able to do on this podcast today. But how do they get a hold of you?

Dr. Roy Shelburne: www.RoyShelburne.com. That's just my name is my website. As far as email RoyShelburne@gmail.com.

Art Wiederman, CPA: Please hang with me as I take my podcast out. And anyway, ladies and gentlemen, this is so important. I mean, you know you want to make sure that you sleep at night and that you're doing everything right. What's best for your patients? And we're very fortunate in our dental world here in the United States to have people like Dr. Shelburne who can help you learn through his mistakes and make sure that it doesn't happen to you again.

Make sure folks that you go to our partner Decisions in Dentistry magazine, www.DecisionsinDentistry.com wonderful clinical content the best articles Great website, great magazine content a who's who of an advisory board clinically from all over the world, going to their website and, you know, read their stuff.

Also, if you're not working with a dental specific CPA, give us a call. Give a member of the Academy of Dental CPAs a call www.ADCPA.org. And again, my contact information is the phone number is six five seven two seven nine three two four three and my email is awiederman@EideBailly.com.

Also want to let you know that I will be speaking I will be doing a day of financial planning on the 28th of July at the National Academy of General Dentistry Meeting. I've been invited to speak there in Orlando, Florida, so I will bring a lot of sunscreen. I actually checked out to see if I could play Bay Hill, where they just played the Arnold Palmer Invitational, and the guy says to me says, Well, you know, he says, we get thunder and lightning most every day. So and it's going to be really hot, muggy. So the green fees are low. So I don't know if I'm bringing my clubs. I'd love to play that course, but anyway, I will be at the National Academy of General Dentistry meeting in Orlando on the 28th. If you are there, please come up into my lecture and say, Hi, I always love seeing my podcast listeners live now that we're hopefully doing live meetings.

So that was Dr. Roy Shelburne. Thank you so much for your time and your what you're doing for the dental profession.

Dr. Roy Shelburne: Thank you so much for the invitation. And giving me a platform. I appreciate it very much.

Art Wiederman, CPA: Wonderful. Well, folks, that is it for this edition of the Art of Dental Finance and Management with Art Wiederman. We got a lot of great stuff coming up this year. Please continue to listen. Please tell your friends, please write reviews. You can download the podcast on Apple and all the different platforms you can download podcasts. If you basically subscribe, you'll get every podcast. We publish twice a month and you'll be able to get the podcast when it comes out during the week and we publish on Wednesdays. Thank you again. Thank you for the honor and time of your privilege and for the Art of Dental Finance and Management. This is Art Wiederman, CPA saying so long until next time. Talk to you soon.