Risk Coding & Dismissals with Evan Sampson
Part two of a two-part series β the CDT codes that trigger payer audits, the legal rules behind discounts and hardship waivers, the mid-treatment dismissal trap, and the compliance infrastructure that protects your license.
Can Auditing Be Avoided?
Insurance payers run sophisticated outlier-detection algorithms across tens of thousands of claims, and the dentist whose CDT codes drift outside the statistical norm is the dentist who gets the audit letter. The triggers are usually one of two patterns β payer data flags you as an outlier, or a cluster of patient grievances brings a board complaint that pulls your records into review. Either path looks back years. Either path can suspend forward payments. And in fraud, waste, and abuse, your malpractice carrier often will not cover the exposure.
Sampson's analogy travels well: driving 42 miles an hour in a 25-zone once is not what gets you pulled over β driving it twice a day for years is. Routine matters. A professional courtesy discount for a family member, a one-time hardship adjustment for an established patient, a single emergency exception β those are not what end careers. Charging different patients different amounts for the same procedure as a habit is what ends careers. The Stark Law has a professional courtesy exception, and hardship waivers are legally allowed, but every exception needs a documented process behind it.
The mid-treatment dismissal is the highest-risk version of the whole topic. Once a patient is in provisionals, has an open endodontic access, or is in active orthodontic therapy, terminating the relationship without a careful protocol β written notice, certified mail, a reasonable emergency-care window β can convert a difficult patient into a patient-abandonment claim. Better to terminate before treatment starts, or refer out cleanly mid-stream, than to walk away.
Two questions every regulator asks first on any incident: was there a written policy on this, and was the person trained on it. Both answers should be yes.
The Conversation
Welcome back to the Dental Digest Podcast with your host, Dr. Melissa Seibert. This is part two of our deep dive into dental compliance, billing accuracy, and asset protection. In this episode, we lean into specific operational risks with healthcare attorney Evan Sampson. We break down the exact CDT codes that automatically trigger insurance audits, how to handle non-compliant patients legally, and how to establish a bulletproof infrastructure within your team so you never have to worry about a state board complaint.
Insurance payers use highly sophisticated data algorithms to scan incoming claims and quickly flag statistical outliers among dental providers. Sampson warns that certain high-reimbursement codes carry inherently high risk from a fraud, waste, and abuse standpoint. Two of the most common pitfalls that attract immediate regulatory scrutiny are upcoding and unbundling. Upcoding involves billing for a higher-tier, more expensive procedure than what was actually delivered to the patient. A classic example occurs during extractions; routine extractions are frequently upcoded as surgical extractions without the required narrative documentation of an incision, bone removal, or a reflected soft tissue flap.
Unbundling is another frequent target for compliance audits. This occurs when a clinician separates the individual components of a single, comprehensive procedure to artificially inflate insurance payouts. For instance, billing separately for local anesthesia or a specialized antimicrobial rinse when those steps are legally bundled into the primary surgical or periodontal code creates immediate red flags for insurance fraud. Even if these coding discrepancies are completely accidental or due to an untrained front-desk team member, the licensed dentist is ultimately held legally responsible for every single claim submitted under their unique provider number.
Beyond billing mechanics, compliance dictates how you manage difficult clinical relationships. Every practice eventually encounters a patient who is consistently non-compliant, abusive to staff, or repeatedly acts against medical advice. While you have a legal right to terminate a doctor-patient relationship, you must execute the dismissal process with extreme caution. Dismissing a patient while they are actively mid-treatment, such as having a temporary crown in place or an open endodontic tooth, can instantly trigger a severe claim of patient abandonment. To protect your license, you must provide formal written notice via certified mail, offer a reasonable grace period for emergency care, and document every interaction objectively.
Building a compliant practice does not require an overwhelming amount of daily stress, but it does require a clear written structure. Sampson recommends creating written, standardized office policies for coding accuracy, template customization, and patient dismissal protocols. Utilize your local state dental societies, consult with specialized legal counsel, and train your administrative team consistently. Putting these defensive structures in place today ensures you can focus entirely on clinical excellence tomorrow. Catch the full episode on the Dental Digest Podcast to master these high-yield protection strategies.
Clinical Takeaways
- Payer audits are usually triggered by one of two patterns: data algorithms flagging you as a statistical outlier on specific CDT codes, or a cluster of patient grievances pulling your records into board review. Both look back years.
- The "42 mph in a 25 zone" rule: occasional exceptions for family courtesy, hardship, or emergencies are defensible. Habitual variation in what you charge different patients for the same procedure is what gets careers ended.
- Mid-treatment is the highest-risk window for terminating a patient. Once a patient is in provisionals, has an open endo, or is in active ortho, dismissing without certified-mail notice and an emergency-care window can become a patient-abandonment claim.
- The two questions every regulator asks first on any incident: was there a written policy on this, and was the person trained on it. If either answer is no, you're starting from a deficit.
- It is always okay to refer out. If a patient asks you to operate above your training, your scope, or your comfort level β even with great rapport, even in genuine pain β referring is the lower-liability and higher-ethics choice.
Chapters & Timestamps
| Timestamp | Topic Covered in Episode |
|---|---|
| [00:00] | Why audits happen β payer data algorithms and grievance triggers |
| [05:14] | Why FWA carries unique risk β the malpractice insurance gap |
| [09:42] | Staying current with CDT β annual code updates and written policies |
| [13:10] | Fee-for-service and out-of-network β when payer scrutiny still applies |
| [16:25] | Discounts, hardship, and the Stark Law professional courtesy |
| [20:08] | The "42 mph in a 25 zone" rule β routine vs. one-off exceptions |
| [24:50] | Difficult patients and the right to terminate the relationship |
| [29:15] | The mid-treatment trap β when dismissal becomes abandonment |
| [34:10] | Trigeminal neuralgia case study β when "I can help" isn't your call |
| [39:05] | Building a compliance culture β policies, training, employee handbook |
Resources
- Post & Schell β Evan Sampson's law firm (Philadelphia, PA)
- ADA CDT (Current Dental Terminology) β annual coding manual
- Stark Law and the professional courtesy exception
- HIPAA β patient communication and online review limitations
- Patient dismissal protocols β certified mail notice and emergency-care window
- Part 1 of this series β Compliance & Charting with Evan Sampson
Evan Sampson, Esq.
Healthcare Attorney Β· Post & Schell
Evan Sampson is a healthcare attorney with extensive experience advising dentists and other healthcare providers on regulatory compliance, fraud and abuse risk, the corporate practice of dentistry, and the legal realities of running a modern dental practice. He has served as general counsel to one of the largest dental support organizations in New Jersey and has held senior compliance leadership roles within the largest municipal hospital system in the country, bringing a rare perspective that sits at the intersection of dentistry, law, and real-world practice operations.
Post & SchellDr. Melissa Seibert
DMD, MS, FAGD, ABGD
Creator and host of the Dental Digest Podcast β the #1 clinical dental podcast worldwide and a top 1% global podcast. Dr. Seibert is a former active-duty U.S. Air Force dentist, internationally sought-after speaker, Key Opinion Leader, and published author in top dental journals. She is passionate about equipping general dentists with high-level, evidence-based clinical skills.
Publications & SpeakingFull Episode Transcript
Dr. Melissa Seibert: Welcome to the Dental Digest Podcast β a show with a mission of enabling you to stay on the cutting edge of evidence-based dentistry. I'm your host, Dr. Melissa Seibert. This is Part 2 of our two-part series with Evan Sampson β a healthcare attorney with extensive experience advising dentists on regulatory compliance, fraud and abuse risk, and the legal realities of running a modern dental practice. He has served as general counsel to one of the largest dental support organizations and brings a rare perspective that sits at the intersection of dentistry, law, and real-world practice operations.
Dr. Seibert: A lot of the fraud-waste-abuse instances you describe are inadvertent β many dentists go their whole careers making them and never get caught. What are typically the precipitating events that get people into hot water?
Evan Sampson: Fraud, waste, and abuse is one of the highest-risk areas a dentist operates in β not because dentists get caught often, but because the exposure is enormous. There's often no insurance coverage, or insufficient coverage. The most common trigger is a payer audit. Payers have very sophisticated data operations β they review tens of thousands of claims and identify outliers. This is especially true in the Medicaid space, where you're dealing with government money. Another trigger: patient grievances. If a number of grievances get filed against you over a period, that can trigger an audit. And sometimes a random board complaint pulls your records into review for an unrelated reason β and the board notices something.
Evan Sampson: If you get caught, it's expensive. They can look back on your books for years. They can suspend forward payments. So it always makes sense to build a culture of compliance β be mindful about documentation. So just in case anything happens, you've made a good-faith effort to protect yourself.
Dr. Seibert: Beyond accurate coding, what are the other best ways to stay out of trouble?
Evan Sampson: Keep yourself educated. The CDT code gets updated every year β if you miss a change, that creates problems. Have written policies and procedures. The ADA and other associations put out guidance, but it doesn't hurt to have a written internal policy so everybody in the office has something to refer to. Your front desk or office manager isn't ultimately responsible, but giving them written materials goes a long way.
Dr. Seibert: What if you're fee-for-service and out of network β do the same rules apply?
Evan Sampson: Potentially less risk, because you're not dealing with insurance companies directly β but you still have an obligation to be truthful and accurate. And it's likely the patient submits the claim themselves for reimbursement, so the insurance company may still get your records. The way it's supposed to work is you charge everybody the same β your usual and customary rate. If you're discounting certain services for certain people, the Board of Dentistry could find out.
Dr. Seibert: What about the discount-for-family-member case? Or charging more for a high-demand aesthetic patient?
Evan Sampson: Different levels of risk. There's the analogy I use with clients: drive 42 miles an hour in a 25-mile-an-hour zone once β you're probably not getting pulled over. Do that every day, twice a day, for years β you're getting pulled over eventually. Routine matters. Discounted services for a family member, most people can understand. But running a large office where every distant relative gets free work β that creates problems. Charging a difficult patient a higher amount β that's risking something. Patients find out, and they can file a complaint.
Evan Sampson: What I recommend: charge everybody the same. Whatever discount program you use has to be legal, compliant, and applied evenly. There are legal exceptions β family members under the Stark Law professional courtesy, hardship waivers β but each requires a written process. The law has exceptions for certain behaviors, but they need a process. Willy-nilly choices get misinterpreted by the wrong person.
Dr. Seibert: Talk to us about unruly patients.
Evan Sampson: Usually it's the ones you don't see coming β that's been my experience as the attorney. The obvious unruly patient β abusive to staff, using racial epithets, denying treatment, demanding more than you ethically can give β those you can identify immediately. I have a zero-tolerance approach. Dentists are far more willing to keep treating these patients than I would be advising them. If a patient is abusive to staff or acting against medical advice, you have no obligation to keep treating. Depending on state law, you can terminate the doctor-patient relationship.
Evan Sampson: The exception is mid-treatment. Terminating mid-treatment is a last resort β it's got to be extreme. This comes up a lot with orthodontists. They tend to treat minors, who aren't responsible for payment. Termination for non-payment is accepted, but staying on top of payment up front or payment plans can be really tricky in ortho.
Dr. Seibert: What about patients who want you to go beyond what you can ethically do? I had a patient this week with trigeminal neuralgia. Multiple sclerosis history, hadn't been diagnosed yet, in genuine 10/10 pain, begging me to write her something. I consulted with my husband, a board-certified anesthesiologist, and even he said he wouldn't feel comfortable. We get into healthcare to help people, and you find yourself in those situations.
Evan Sampson: I can't give you specific legal advice on that case, but you have an ethical obligation to be competent. You are a fiduciary for your patients β you have to act in their best interest and do no harm. If you are not competent to treat or it's beyond your scope, it's okay to say no. It's okay to ask for help. Refer the patient. You can tell them to call their insurance for in-network options. You have no obligation to do something you don't feel comfortable doing.
Dr. Seibert: What about mid-treatment dismissals β veneer case in provisionals, things have gone downhill?
Evan Sampson: If you haven't started the treatment, that may be the perfect opportunity to terminate β or to refer them to a specialist if you're having second thoughts. If you've started, you have to use your best judgment. Acting too swiftly and terminating, or referring too late, risks a patient-abandonment claim. Don't be afraid to ask for help.
Dr. Seibert: Should it be documented if you refer a patient out?
Evan Sampson: Document everything. And sometimes patients need to sign a release β especially when you're refunding the patient as part of resolving a dispute. Things can go badly even when you've done everything right. I represent dentists where the patient got a second opinion confirming the dentist did everything correctly, and the patient is still angry. Part of being a dentist is customer service. That's where I come in as the attorney β helping navigate those situations. Part of your job is to protect your license. Anyone can file a complaint with the board.
Dr. Seibert: Are there red flags for difficult patients?
Evan Sampson: Two kinds. The obvious problematic patients β abusive, non-compliant. And then the ones where out of nowhere you get a board complaint from someone you've treated for years. Those are the ones I see most often. All you can do is treat everyone the same, do your best job, and talk to resources who've been through similar situations. Yelp and Google reviews are a real pain point β you want to respond, but HIPAA prohibits it.
Dr. Seibert: Walk us through how to build a compliance culture.
Evan Sampson: The first two questions any regulator asks when something goes wrong are: was there a written policy on this, and was the person trained on it? If the answer is no to either, that's a problem. Start small, build bit by bit β written policies and procedures, regular training, open lines of communication, clearly written grounds for staff discipline. Collect copays and deductibles upfront. Have an employee handbook. The first question in any staff incident is "what did your handbook say?" If your answer is "we didn't have a handbook," that's a problem.
Dr. Seibert: If people want to work with you or get a hold of you, how should they reach out?
Evan Sampson: Email me at [email protected], or call 856-301-2561.
