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Providing proper treatment and care is the prime focus of every dental practice, but submitting correct claims is critical to increase cash flow and improve collection rates. This depends on knowing the rules and regulations of insurers and following proper coding and billing practices. Outsourcing dental insurance eligibility verification and dental billing to an experienced service provider is a practical option for practices to improve their bottom line as well as avoid common billing mistakes that could be counted as fraud and abuse. Let’s take a look at 7 top dental billing mistakes to watch out for.

  • Upcoding: This is considered a major fraud. Upcoding means billing for services that are more expensive than that which was actually provided. For instance, in one case, a dental office submitted bills for fillings on eight teeth when the dentist only provided non-covered sealants ( Upcoding involves using codes for services the patient did not receive, or codes for more intensive procedures then the provider actually performed. The American Dental Association (ADA) defines upcoding as “reporting a more complex and/or higher cost procedure than was actually performed.” Upcoding to evade insurance rules and get more money from the payer is closely scrutinized by insurance companies and regulatory agencies. Dentists should only bill for the level of services or items actually furnished.
  • Bundling: The American Dental Association (ADA) defines unbundling of procedures as “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 is using several CDT codes (unbundling) to report a service on a claim when actually one code is sufficient to capture payment for the component parts. For instance, a crown has numerous parts such as anesthesia, prep, impressions, temporary crown, etc. and each of these do not require a separate code. Unbundling can be an inadvertent error or done deliberately to increase practice reimbursement. Practices should be familiar with applicable payer rules on which services are bundled or billed together.
  • Billing for Services not Provided or not Completed: Billing for services not performed or not completed is another type of dental billing fraud. Examples include billing for surgery when the treatment provided was nonsurgical, billing for a crown at the prep time or before it is cemented. However, if a crown is prepped and not cemented, the dentist can claim partial payment from the insurance company.
  • Waiver of Copayment or Deductible: Both government and private insurance companies do not allow dentists to waiving patients’ deductibles or co-payments. Patients are responsible for copayments and deductibles. If providers waive co-insurance requirements, it is considered fraud because it results in false claims, violations of the federal Anti-Kickback Statute, and excessive use of items and services paid for by the insurance carrier (
  • Misrepresenting or Altering Dates of Service: This unscrupulous practice involves reporting that a service for a particular patient was provided on two separate days instead of on the same day. Each “office visit” is usually regarded as a separate billable service and falsifying the date of service is done to take advantage of this. The date on the patient’s medical file documentation should match the date of service listed on the claim form.
  • Medical Identity Theft: This involves the misuse of the patient’s unique medical identifying information to obtain or bill public or private insurance carriers to fraudulently obtain medical goods or services. physician identifiers can also be stolen to fill fake prescriptions, refer patients for additional services or supplies that are not needed, or bill for services that were never performed. To prevent unauthorized use, dental practices should take appropriate measures to protect their dentists’ and patients’ identifying information.
  • Not Verifying Patients’ Insurance Eligibility: Oftentimes, front desk staff may assume that an established patient’s insurance coverage has not changed. But if it has and dental eligibility is not checked, the provider may get into trouble. Terminated coverage, services not authorized, services not covered by plan, or maximum benefits reached and additional or primary coverage must be verified to prevent errors in claims.

False claims can lead to severe penalties, loss of reputation and patient ire. The best way to avoid unintentional fraud, is to maintain accurate documentation of all services provided. Partnering with an experienced dental billing company can ensure proper dental billing practices and error-free claim submission.

Amber Darst

Amber Darst is our Solutions Manager in the Healthcare Division, Practice and RCM. With a rich background in dental services, her expertise ranges from insurance coordination to office management.

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