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Dental practices are under increasing scrutiny by Medicare, commercial insurance companies and regulatory bodies after recent reports of dental billing fraud and abuse. While partnering with a dental billing company can help maintain practice integrity and compliance, it is important for dental practitioners to be aware of what constitutes billing fraud to avoid inadvertent mistakes.

  • Having an unlicensed staffer perform dental procedures: A Connecticut dentist made headlines for the wrong reasons in August this year after a judge found that he had illegally billed Medicare for pediatric dental cleanings and fluoride treatments done by unlicensed assistants. The court ordered him to pay $770,046 for improper billing of these dental procedures performed between April 2002 and December 2009.
  • Submitting inflated and false insurance claims: Billing insurance for more expensive procedures than those actually performed or billing for procedures that were not performed are serious offences. Examples include upcoding a simple extraction to a more complex procedure or falsely representing a routine cleaning as a costly deep cleaning.
  • Unbundling: According to the American Dental Association, unbundling of procedures is: “the separating of a dental procedure into component parts with each part having a charge, so that the cumulative charge of the components is greater than the total charge to patients who are not beneficiaries of a dental benefit plan for the same procedure.” Unbundling refers to using several codes to describe a service on a claim where one code is sufficient. For example, the dentist performs an extraction and bills for elevating the flap, curetting out the tissue, incision, drainage and suturing, when all these procedures are actually part of the global fee for extraction of the tooth.
  • Waiving copayments and deductibles: Co-payments and deductibles are considered to be essential part of the insurance company’s contract cost structure. Routinely waiving these components is considered illegal. For instance, if a patient is charged $100 and the payer is billed for $80, the patient’s copay is $20. If the dentist does not collect the $20 from the patient, this means that the charge for the service provided is $80 and not $100. This means that the insurance company$ owes only 80% of $80, which is a misrepresentation of the cost of the service. Different states have differing policies on what constitutes fraud and dentists need to be aware of their state’s rules and regulations.
  • Fraudulent diagnosis and billing: An outright fraudulent diagnosis would be when a dentist recommends implants or bridgework where a simple removable appliance would suffice.
  • Misrepresentation of patient identities and dates of service: Treating one patient and sending in the claim for this patient as someone else is an obvious example of fraud. The date on which a procedure is performed is connected to the patient’s medical eligibility and waiting periods.

Fraud can lead to heavy fines, penalties, and even exclusions from certain healthcare programs. It has been found that many dentists are unaware that their office may be committing fraud. Dental practices can avoid questionable billing practices by opting for outsourced dental billing services. An established dental billing company will have professionals on the job who will audit and scrutinize each claim before submission to ensure that data is reported accurately and consistently and in compliance with HIPAA requirements and the rules and regulations of government and commercial insurance carriers.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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