Small Business and Practice Reference

June 17, 2020
The U.S. Department of Health and Human Services has amended the final rule on Section 1557 of the Affordable Care Act to no longer require health care providers to include notices related to nondiscrimination and language assistance services in all significant communications.

Another amendment permits remote English language interpreting services to be audio based instead of video based.

The amendments are effective Aug. 18, 2020.


On May 18, 2016, the U.S. Department of Health and Human Services published a final rule under Section 1557 of the Affordable Care Act to protect individuals from discrimination in health care on the basis of race, color, national origin, age, disability, and sex, including discrimination based on pregnancy, gender identity, and sex stereotyping. Section 1557 is enforced by the Office for Civil Rights, the federal agency that enforces HIPAA.

Advertising requirements for dentists are noted in Mississippi State Board of Dental Examiners Regulation 43.

All advertisements must include the full name and degree of the dentist who will be providing services. No advertisement by a licensed dentist shall contain any false, fraudulent, misleading, or deceptive statement or claim.

The Americans with Disabilities Act, a federal law that prohibits discrimination in access to services and employment against persons who are disabled, was enacted in 1990.

All dentists are required to follow the requirements set forth in the Act. The ADA provides valuable information or you may call ADA Legal Affairs 800-621-8099 for specific consultation. The official website for the Americans with Disabilities Act.

MSBDE Regulation 29 addresses this area for Mississippi dentists. 

The regulation:

• defines the terminology of anesthesia and sedation,
• defines guidelines for utilization and permits and 
• lists criteria and fees in the application for anesthesia permits.

Mississippi law requires dentists to report any reasonable cause of child abuse or neglect that may be observed in examination, care or treatment of a child. Dentists who in “good faith” report such observations are also immune from any liability under Mississippi law. 65% of child abuse cases involve injuries to the head, neck and face. 

Dentists should provide the following information upon a report of suspected abuse or neglect:
   - name of child and parents or caretakers along with contact information
   - child’s age
   - nature of the child’s condition, including any previous injuries or disabilities
   - any other pertinent information relating to the cause for suspected abuse or neglect 

Dentists should also carefully document:
   - time and date the injury was observed
   - location and number of injuries on the body
   - color and size of each injury
   - child’s and parent’s verbal response
   - any other pertinent information
   - have another individual within the office witness the exam and co-sign the record

How to file a report:
For emergency follow up, call Mississippi Department of Human Services Centralized Intake - Child Abuse Hotline: 601-359-4991 or 800-222-8000.
NOTE: If the situation is a life-threatening emergency, call your local law enforcement agency or 911.

For reporting that does not require an emergency response, submit a report on-line to Mississippi Department of Human Services: click here. 

Dentists must obtain a minimum of forty (40) hours of continuing dental education, and dental hygienists must obtain a minimum of twenty (20) hours of continuing education. The accrual and reporting period is a consecutive two (2) years and runs from from January 1 through December 31 of each year effective January 1, 2014.

MSBDE approved continuing dental education shall consist of courses approved by the American Dental Association (ADA), Academy of General Dentistry (AGD), Mississippi Dental Association (MDA), Mississippi Dental Society (MDS), National Dental Association (NDA), or other courses or activities specifically approved by the Board for CDE credit. 

No more than four (4) hours per year on the subject of CPR (Cardiopulmonary Resuscitation) shall be allowed toward the two-year, forty-hour requirement, and dentists successfully completing an eight-hour, two-year CPR certification course are allowed to use four (4) hours each year, of the total eight (8) hours, toward fulfilling the two-year, forty-hour CDE requirement. Furthermore, licensees successfully completing a 16-hour Advanced Cardiac Life Support (ACLS) course may use eight (8) hours each year, of the total sixteen (16) hours, toward fulfilling the two-year, forty-hour CDE requirement, and licensees successfully completing an 8- hour ACLS course, a Board-approved general anesthesia review course, or an equivalent Board-approved course, may use four (4) hours each year, of the total eight (8) hours, toward fulfilling the two-year, forty-hour CDE requirement. Finally, dentists may attend courses offered and approved by any of the additional organizations listed in Section 3 of this Regulation and use such attendance as a means of fulfilling continuing education requirements.

These CDE requirements can be referenced in MSBDE Regulation 41.   

The Mississippi State Department of Health regulates the on-site storage and management of medical waste and infectious medical waste through the "Adopted Standards for the Regulation of Medical Waste in Health Care Facilities Licensed by the MS State Department of Health". 

For more specific information on these standards, contact the MSDH at (601)576-7300. 

For specific information on the regulation of commercial management of medical wastes, contact the Solid Waste Management Branch at the Mississippi Department of Environmental Quality (MDEQ) at (601)961-5171.

Dental Waste Information and Recyclers

The Mississippi Department of Environmental Quality (MDEQ) has provided the following information resources on recycling, waste management and pollution prevention for Mississippi dentists:

Mississippi Medical Waste Fact Sheet  
Pollution Prevention and Waste Management for Dental Offices
Mississippi Recycling Directories 

A reference list of dental waste recyclers can also be located on the ADA website. This directory includes national companies that handle dental amalgam and radiographic related waste. This resource also includes a suggested list of questions to assist the dentist in making a recycler selection.

Finally, to better assist our members in dealing with dental waste, the MDA has endorsed DisposeALL.

For a license to write prescriptions or additional information in Mississippi, contact:
DEA Offices & Telephone Numbers for Mississippi  
        Gulfport   228-863-2292
        Jackson  601-965-4400
        Toll Free 1-800-882-9539

Their website is also a quick method to access information and apply for or renew drug license registration:  ​ 

Mississippi does not require dentists to have a state registration number, just a federal registration number.  

What is an Electronic Health Record?

An electronic health record (EHR) is an evolving concept defined as a systematic collection of electronic health information about individual patients or populations. It is a record in digital format that is capable of being shared across different health care settings, by being embedded in network-connected enterprise-wide information systems. Such records may include a whole range of data in comprehensive or summary form, including demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats like age and weight, and billing information.

Its purpose can be understood as a complete record of patient encounters that allows the automation and streamlining of the workflow in health care settings and increases safety through evidence-based decision support, quality management, and outcomes reporting.

The ADA has compiled a wealth of information and resources on EHRs.
This information is designed to not only inform dentists about EHRs but to also provide the necessary tools to assist them in making decisions about the implementation of EHRs into their practices.

What about Mississippi Health Care Providers? How can Mississippi dentists take advantage of the incentive program if we want to implement EHR systems in our practices?

The Mississippi Division of Medicaid has developed information for Mississippi Health Care Providers. Click here for concise information and instructions on how to sign up.  

More information EHR Incentive Program from the Centers for Medicare and Medicaid Services.     

A good, concise article by Laney Kay, JD provides helpful information for dentists - Handling Confusion Regarding Electronic Health Records and HIPAA-Governed Breach of Patient Information

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Ten Things You Must Do

When you hire your first employee, you become subject to an array of registration and filing requirements. Here they are.

1. Obtain a federal employment identification number by filing IRS Form SS-4.  This form is available from the IRS website.

2. Register with your state's employment department for payment of unemployment compensation taxes. These payments go to your state's unemployment compensation fund, which provides short-term relief to workers who are laid off. Mississippi Department of Employment Security.​

3. Set up a payroll system for withholding taxes and making payroll tax payments to the IRS. You'll need to withhold a portion of each employee's income and deposit it with the IRS, and also make Social Security and Medicare tax payments to the IRS. For more information, obtain IRS Publication 15, Circular E, Employer's Tax Guide from the IRS website. (You also have to withhold taxes for your ​Mississippi. For more information, check with the ​Mississippi Department of Revenue.)

4. Get worker's compensation insurance. If you have five (5) or more employees, you must have this insurance coverage, in case a worker suffers an on-the-job injury. (In addition, you must notify new hires of their rights to workers' compensation benefits.) You may purchase this insurance from your insurance agent/broker. NOTE: The MDA endorsed insurance broker is Brown and Brown.
 
5. Prepare an Injury and Illness Prevention Plan. This is one of the requirements of the Occupational Safety and Health Administration (OSHA). For information on compliance with this and other OSHA regulations, go to the OSHA website. 

6. Post the required labor notices in your workplace. For information on required federal posters, go to the Department of Labor website. Use their online "Poster Advisor" to determine which posters you must display in your workplace. In addition, you must comply with your state department of labor's poster requirements. A list of state departments of labor is included on the federal Department of Labor's website.

7. Create an employment application for each type of position you will fill. You can easily find a safe and legal employment application in computer business software programs or in materials designed for the dental office and available for purchase through the ADA. ADA Employee Policy Manual. 

8. Create an employee handbook. Although not required, it is an excellent idea to have a handbook describing your business's employee policies and making it clear that employment is at will unless an employee has signed a written employment contract. As noted earlier, the ADA has a handbook designed specifically for the dental office. 

9. Create a sign-up procedure for employee benefits. If your business has established employee benefit programs such as health insurance or a 401(k) plan, you'll need a sign-up procedure so employees can name their dependents and select options.

10. File IRS Form 940-EZ to report your federal unemployment tax each year. You must file this form for any year in which you paid wages of $1,500 or more in any quarter or for any year in which an employee worked for you in any 20 or more different weeks of the year. (You must use IRS Form 940 instead of Form 940-EZ if you paid unemployment contributions to more than one state or if you did not pay all of your unemployment contributions by January 31.) You can find both forms on the IRS website.

* Report the employee to your state's new hire reporting agency All employers with business operations in Mississippi are required to submit New Hire reports as required by Federal Law, Public Law 104-193. You may report electronically in Mississippi. 

* Complete Form I-9, Employment Eligibility Verification. U.S. Citizenship and Immigration Services (USCIS, formerly known as the INS) requires employers to use this form to verify that every employee they hire is eligible to work in the United States. (You don't have to file this form with the USCIS, but you must keep it in your files for three years and make it available for inspection by officials of the USCIS.) You can obtain the form online.

* Have the employee fill out IRS Form W-4, Withholding Allowance Certificate. On this form, employees tell you how many allowances they are claiming for tax purposes, so that you can withhold the correct amount of tax from their paychecks. (You don't have to file the form with the IRS.) You can find this form on the IRS website. 

State and federal laws require employers to display specific posters. 

Mississippi Department of Employment Security Commission (MDES)
1520 W Capitol Street
PO Box 1699
Jackson, MS 39215-1699
(601) 321-6428

Mississippi posters required by MDES: 

Unemployment Insurance Poster
The Mississippi Department of Employment Security provides the Unemployment Insurance poster at no charge. You may download it or call 601-321-6428.

Mississippi Workers' Compensation Poster
This poster is available for offices of five or more employees by visiting the Mississippi Workers’ Compensation website.


The federal government may require the following posters - depending on the specific size and staff composition of the dental office:

Employee Polygraph Protection Act    (EPPA)
Employee Right for Workers with Disabilities/Special Minimum Wage Poster
Equal Employment Opportunity is the Law
Fair Labor Standards Act Minimum Wage Poster 
Job Safety & Health Protection
Uniformed Services Employment and Reemployment Rights Act (USERRA)
Your Rights Under the Family and Medical Leave Act 

All of these required posters may be downloaded from the US Department of Labor website.

The Community Water Fluoridation Program in our state is one of the best ways to prevent tooth decay and help maintain healthy teeth. Fluoridation adjusts the amount of fluoride in drinking water for those communities whose natural water fluoride level is low. Grant funds are available to assist with the cost of fluoridation in some cases on a first-come, first-served basis through the Mississippi State Department of Health.

The MSDH provides an array of information about water fluoridation on their website.   Specific information on public water systems, including fluoridation status, may also be found on the MSDH Dental and Oral Health website. 

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U.S. Department of Health and Human Services has amendment permits of  remote English language interpreting services to be audio based instead of video based.

The amendment is effective Aug. 18, 2020.

Do dentists have to hire sign language interpreters for hearing impaired patients?
In some cases, yes. Under the Americans with Disabilities Act (AwDA), a dental office is a place of public accommodation and is prohibited from unlawful discrimination by reason of disability. A place of public accommodation may not discriminate against people whose hearing impairments render them disabled as defined by the AwDA and must supply “auxiliary aids and services,” such as sign language interpreters, when necessary to ensure effective communication, unless doing so would cause an undue burden.

Sometimes dentists must retain the services of sign language interpreters and in other cases this is not required. The AwDA requires you to make the services of an interpreter available if one is needed to achieve equally “effective communication” with the hearing impaired individual (the patient or prospective patient or their legal surrogates, if any). Communication may vary individual-to-individual (some deaf patients prefer reading lips and others do well exchanging notes) and even treatment-by-treatment (an interpreter may be needed for a complex procedure, but perhaps not for a simple one such as a prophy).

The dentist should assess the need on a case-by-case basis. When deciding whether an interpreter is necessary, consider the needs and preferences of the individual and the complexity and length of the communications that will be involved. Consider whether you will need an interpreter to secure an informed consent, or whether you will need an interpreter if foreseeable complications arise. A dentist will usually know in advance if a patient has a hearing impairment — practices often ask all new patients if they need accommodations of any kind when scheduling appointments. If so, discussions about appropriate accommodations may be held in advance of the office visit. The National Association of the Deaf (NAD) advises deaf and hard of hearing persons: “Make your request for reasonable accommodation as early as possible. It often takes time to find a qualified interpreter, or other auxiliary aids or services.”  

The requirement to provide auxiliary aids and services can extend beyond the patient’s needs. For example, if a child can hear but his or her parents are hearing impaired, you may need to hire an interpreter to communicate with the parents to achieve effective communication. Of course, this effective communication is a good idea for risk management purposes as well and can help you make sure that the parents have given informed consent for treatment of their child. For HIPAA Covered Entity practices, a sign language interpreter may be a Business Associate because he or she is likely to receive patient health information in the course of providing interpretation services. Therefore, the interpreter may be required to sign a HIPAA Business Associate Agreement prior to providing services. Keep in mind that the HITECH Act amendments to HIPAA increase the responsibilities of Business Associates and the Covered Entities that contract with them.   

Who pays for the interpreter?
I’d lose money if I had to pay. If an interpreter is used because sign language skills are needed to achieve equally effective communication, the dentist must pay for the services and cannot pass the charge along to the hearing impaired individual. However, this does not mean that the dentist must pay any time a patient brings an interpreter to an appointment. Indeed, NAD goes on to advise: “Do not hire your own interpreter and expect the doctor/health care provider to pay your interpreter for you. You may run into problems that way.”

If an interpreter is necessary to achieve effective communication, the simplest approach may be to pay the interpreter’s charges for the initial visit, and if they are high, explore other interpreter options for future visits. A well-prepared dentist can have on hand a list of readily available resources, perhaps including lower cost interpreters (such as interpreters provided through local social service, religious, or government funded agencies). The best resources will vary locally, and sometimes they can be found through disability support groups such as the local hearing society or Easter Seals branch.

Dentists cannot insist that patients use friends or family to interpret. A dentist may wish to claim that providing an interpreter is an undue burden, but the interpreter’s fee is measured against the practice’s overall financial picture, not the treatment in question. Accordingly, the dentist will typically be required to pay for the interpreter’s service. Dental offices may qualify for a tax credit of 50 percent of the cost of interpreter services between $250 and $10,250 expended in a given year.

Don’t forget, the key is achieving effective communication.

Medicare is the national health insurance program for: 
         -People age 65 or older
         -Some people under age 65 with disabilities
         -People with end-stage renal disease (ESRD), which is permanent kidney failure requiring dialysis or a kidney transplant.

Under present law, the Medicare benefit does not include coverage of most dental services. Some insurers have required dentists to receive a claim denial from Medicare before they will process a claim from the dentists for a Medicare beneficiary holding coverage from a group health insurer. A group health plan cannot require dentists to obtain a claim denial from Medicare for dental services that are not covered by Medicare before paying the claim. However, a claims determination may be required for inpatient dental hospital services or dental services specifically covered by Medicare. For additional information regarding Medicare, dentists may reference their website. 

General Information about Medicare Provider Enrollment for Dentists: Please note that this information is subject to change. This information is not intended to provide either legal or professional advice, and cannot address every federal, state, and local law that could affect a dentist or dental practice.

As of January 1, 2019 dentists must be enrolled as Medicare providers or have formally “opted-out” in order to prescribe drugs or bill for procedures for those patients that have Medicare coverage. In order to be ready for the implementation date, dentists must submit a Medicare enrollment application or opt-out affidavit by J​anuary 1, 2019 to ensure sufficient processing time and avoid having their patients’ prescription drug or treatment claims from being denied by Medicare. 

The ADA has developed some helpful resource tools for dentists to utilize in determining their enrollment decision. They can be referenced here. 

A dentist must give a patient his/her records upon request; however, the dentist may charge a reasonable fee for reproduction of these records. This fee should not exceed the costs incurred by the dentist for reproducing all records, including radiographs.

To refuse to give a patient his/her records violates the ADA Code of Ethics and Mississippi Board Regulation 53. 

In Mississippi, patient records should be maintained a minimum of seven (7) years from the date of the last treatment before they can be destroyed.

The National Practitioner Data Bank (NPDB) contains information about dentists and other licensed health care practitioners who have had adverse actions taken against them with respect to their professional competence or conduct, or who have had payments made on their behalf in response to written claims of malpractice.

Complete information on the NPDB is available on their website. From the NPDB website, a dentist can download the forms for initiating a self-query. The NPDB also publishes a quarterly newsletter that provides information about NPDB operations. A copy can be downloaded from the website. To contact NPDB by phone, call (800) 767-6732.

The NPI is a unique, government-issued standard ID number for individual health care providers and provider organizations like clinics, hospitals, schools and group practices. The NPI is a 10-digit number assigned to providers via the following advantages:
- replacement of SSN or Individual Tax ID numbers on standard electronic transactions (note these will still be used for tax purposes),
- dentist providers can use one number versus multiple ID numbers presently required by dental plans and
- standardization should facilitate efficiency in claims processing.

Need more information?  As always, more information and education on the NPI can be found on the CMS website.

Applying for an NPI is free and relatively easy. Providers can apply for an NPI online or can call the NPI enumerator to request a paper application at 1-800-465-3203. The process should take 20-30 minutes. Obtaining an NPI will be a requirement for all dentists in the future, even those who do not submit claims electronically. 

The Mississippi Division of Medicaid requires all Medicaid healthcare providers to have on file with Medicaid a National Provider Identification (NPI). Claims filed for Medicaid payment will deny if this number is not in their files.

The Mississippi Chapter of the American Academy of Pediatrics developed a screening guide to assist and encourage pediatricians to conduct oral health screenings and make referrals to dentists upon identification of treatment need.

Click here to download a copy of the oral health screening tool.  

MSBDE Regulation 55 indicates that shareholders of professional corporations which render dental services shall be licensed dentists. If the dental practice is not incorporated as a professional corporation, anyone can own the practice.

Furthermore, any dentist employed to render dental services here in Mississippi must be a currently licensed Mississippi dentist, and all decisions are the sole responsibility of the licensed Mississippi dentist.  

The owners, under no circumstances, interfere with the licensed Mississippi dentist's treatment.  

Prescription Monitoring Program  (MSPMP) is Mississippi’s solution for monitoring Schedule II-V controlled substances dispensed in Mississippi. Mississippi State Statutes 73-21-127, 73-21-97 and 73-21-103 set forth the legal requirements for reporting Schedule II-V controlled substances dispensed in Mississippi for use in the PMP system, plus a few additional drugs specified by the state, such as Soma (carisoprodol), tramadol, and butalbital. 

- Data Submission. Information about controlled substance dispensing activities is reported regularly to the state of Mississippi through their authorized data collection vendor. Pharmacies and other dispensers (clinics, etc.) that are licensed by the Mississippi Board of Pharmacy are required by law to provide such reporting to the data collection vendor in approved formats and frequencies. This includes mail order pharmacies that mail orders into the state.

- Report Retrieval. Mississippi’s online reporting application allows authorized users to generate customized reports 24 hours a day, seven days a week. A report shows information for all the scheduled prescriptions a specified patient has had for a specified time period. An authorized user can be a prescriber for medical treatment of an existing patient, a pharmacist for pharmaceutical treatment, a law enforcement officer with an active investigation, a licensure board for a licensee, Medicaid for a Medicaid recipient, a grand jury by subpoena, or a judge, probation or parole officer administering a drug diversion or probation program.
 
The primary beneficiaries of the Mississippi PMP are patients throughout Mississippi. Because of the Mississippi PMP, healthcare providers can make more informed treatment decisions that allow them to provide the most appropriate medical care for their patients. However all Mississippi citizens ultimately benefit through improved medical care and reductions in the abuse and diversion of controlled substance prescription drugs.
 
How to Register to Retrieve Patient Controlled Substance Usage Reports
Go to the Mississippi Pharmacy Board Website to register.

Important to Note: The ability to access a patient's history of controlled substance provision is a valuable tool to aid in the prevention of abuse. Dentists who are registered and provided the ability to access that information should also be aware that those who seek to obtain confidential information of this nature are also monitored in the system. A health care professional should not seek to access information that does not directly relate to patient care.
 
 

The Mississippi State Department of Health requires dentists to register their radiographic equipment and have subsequent inspections of the equipment conducted. To contact the MSDH, you may call (601) 987-6893.
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Anyone other than a licensed dentist who desires to use ionizing radiation procedures in dentistry must obtain a radiology permit from the MSBDE unless otherwise exempted per MSBDE Regulation 25.  

By reviewing information on mistakes that other dentists have made, you may be able to identify opportunities to improve your practice. Based upon claims experience, many insurance companies offer recommendations on how allegations of malpractice can be avoided. They also suggest ways dentists can improve their ability to defend themselves against an unfounded allegation. This information is provided by insurance companies through risk management newsletters distributed to their policyholders. The MDA endorses Fortress Insurance Company for dentist professional liability coverage. Fortress provides risk management programs for dentists as well as a wealth of risk management information on their website.

 

According to the ADA “Principles of Ethics and Code of Professional Conduct”, the following items should be considered when terminating dentist-patient relationships:

- During a course of treatment, the dentist should not discontinue that treatment without giving the patient adequate notice (30 days) and the opportunity to obtain the services of another dentist.  If there is an emergency within the 30 day notice you must see the patient.
     
- Lack of payment: Whether and when treatment can be stopped also raises questions of patient abandonment, which is a state law issue. Accordingly, consultation with an attorney is important. As a general rule, most states require completion of treatment, and the patient's payment obligation is viewed as a separate issue. Stopping treatment over payment delays or disputes is thus problematic. If there is proper documentation establishing a patient's obligation in place, a prudent course of action might be to send the account to collection and/or initiate litigation to recover what is owed, while at the same time finalizing whatever treatment must be completed to avoid a suit for abandonment.
     
- Unruly patients: Again whether and when treatment can be stopped raises questions of patient abandonment, which is a state law issue. Consultation with a private attorney is important. As a general rule, most states require completion of treatment, unless the patient poses a risk to the dental team or makes completion of care impossible. Of course, if a patient's unruliness is caused by a disability, the office may be required to offer a reasonable accommodation to the patient before stopping treatment.           

Click here to reference the Mississippi Tax Code. 
Look under Reference: Laws, Rules & Regulations, go to State Tax Commission Rules and Regulations, go to Title 35 - Mississippi State Tax Commission, go to Part IV - Sales and Use and finally Chapter 03 - Dental Laboratories and Dental Supply Houses.

Specifically for dentists: "The gross income received by dentists in the performance of their professional services is not subject to the provisions of the Sales Tax Law. Dentists are considered as the users and consumers of all materials, supplies and equipment purchased by them for use in their dental practice. Therefore, all sales made to dentists are retail transactions taxable at the regular rate of sales or use tax."

The majority of Mississippi employers are required to join the fund. To protect themselves, Mississippi employers should consider the following:
- prepare detailed job descriptions,
- conduct effective job interviews,    
- establish a written hiring agreement, and
- establish a disciplinary system and termination procedure.

The ADA provides dental office specific materials to assist in development of policies and procedures. Contact ADA Salables Department at (800) 947-4746.

For more information on Mississippi unemployment compensation, go to their website.

The basic requirements for Mississippi employees collecting unemployment are:
- You must have been employed. The Mississippi Employment Security Commission publishes requirements for wages earned or time worked during an established period of time referred to as a "base period."
- You must be determined to be unemployed through no fault of your own as defined under Mississippi law.  
- You must file ongoing claims and respond to questions concerning your continued eligibility.  
- You must report any earnings from work and any job offers or refusal of work during any claim period.
- Meet any other unemployment eligibility requirements of Mississippi law.    
- Mississippi law provides that discharge for drug use constitutes willful misconduct and disqualifies an employee from receiving unemployment compensation.