Fraudulent Dental Billing Did you realize that even innocent mistakes with your dental insurance might result in a claim of fraud? The question on your mind is, “How might someone accidentally do something unethical?” However, the reality is that it occurs much more frequently than you may realize.
After working in the dentistry field for a while, we have seen many businesses undergo audits, and a few dentists lose their licenses or even go to prison due to fraud in their practice. When it comes to fraud, ignorance is rarely an acceptable justification.
Dental Revu feels strongly about this issue because we value dentists and our colleagues at the office. We’re eager to lend a hand in expanding your financial resources, but only within the bounds of the law. Discover how even seemingly insignificant billing errors can lead to fraudulent dental billing and put your practice at risk of legal repercussions in this informative article. Don’t lose money to fraudulent dental billing practices! Arm yourself with these seven helpful tips to ensure a secure and profitable dental business.
Tips to avoid fraudulent dental billing
- Misidentifying the treating dentist
Most dental insurance claim form fraud occurs. Preferred Provider Organization (PPO) doctors sign contracts to write off a portion of the usual service price. This charge determines patient costs. To receive the network charge for the patient, the claim filer will name the in-network physician as the treating doctor on the claim form if the associate dentist needs to be credentialed. This is usually monetarily driven, especially when insurance doesn’t cover out-of-network benefits. It also helps patients get the best out-of-network benefit rather than none. Most employers are self-funded, meaning they use an insurance firm like Dental Revu to administer their plan and make payments, but they pay for it themselves. An employer-funded dental benefit trust pays those benefits. Dental Revu saves money by encouraging patients to see in-network dentists if they limit their benefits from seeing an out-of-network dentist.
Incorrect reimbursement calculations lead to fraudulent dental billing. You may need to know who to put on the claim form in states that allow doctors other than dentists to provide services. In states that allow hygienists to give services without a doctor, the treating provider must be the doctor who routinely sees the patient or diagnoses and recommends the service. Simply enough, the claim filer must fill out the “treating provider” part accurately. On the dental claim form, it’s fraudulent to designate the owning dentist as the treating dentist when a different provider provides services to acquire network membership. It’s deceptive. Out-of-network dentists affect benefits.
Unbundling (charging separately
The American Dental Association (ADA) establishes billing codes for services delivered that may include so many steps per service that unbundling services to charge individually or overcharging for procedures becomes inevitable. It is dishonest to break down dental care into its sections and charge more than the entire cost of what should be considered a single procedure. A dentist may, for instance, have to remove the tooth, raise the flap, curettage the periapical tissue, make an incision, drain the site, and suture the socket to complete an extraction. If the dentist added up each of these, it would be fraudulent dental billing.
Accident causes dental insurance claim fraud
To illustrate how a simple slip-up on the claim form can result in a false claim, consider the following scenario. After tripping and falling in the kitchen, a man walks in with a broken front tooth. You must specify that the medical care was required due to an accident on the claim form. This field is typically left blank in dental software. That requires intervention from human hands. Consequently, it is vital to identify the specific nature of the accident. What kind of insurance did your company have in place for your employees? Has there been a car crash? When a dentist’s office’s staff doesn’t know how to enter that information manually or doesn’t see why it’s important to describe the claim in light of the accident, they often send it out, get paid, and go on. They got the money the dentist wasn’t entitled to since they didn’t tell anyone it was for accident-related dental work, and they had yet to learn. The dental insurance company won’t have to foot the bill for that claim until the medical insurance company or another third party has looked into it.
Coding errors can potentially lead to fraud in practice
Take, for example, a patient with periodontal disease who requires four annual checkups. The hygienist will record a prophy for periodontal maintenance twice a year using a code. They report it as a prophylaxis (cleaning) because their insurance covers two years and two periodontal maintenance procedures. Due to the hygienist’s double-counting of the periodontal maintenance procedures, the patient is eligible for benefit reimbursement. The dentist gets benefits for which they are not legally eligible because of a down-coding error. The dentist was overpaid due to down-coding, reporting service as less extensive than what was performed. However, up-coding is a real thing.
On the contrary, down-coding is done. One such case is a person with an impacted tooth that has become bone. The surrounding bone is scraped away using a dental bur, and the tooth is either sectioned or extracted. Although it was reported as a surgical extraction, it was simple. This procedure is not one of the higher-paying surgical extraction codes.
Wavering Copayments and Deductibles
Dentists who continue to charge insurance companies the same amount after patients’ deductibles and copayments have been waived are engaging in fraudulent dental billing. Overcharging clients is a kind of fraud and a crime. Even though doctors and hospitals may think they’re doing their patients a favour by waiving these costs, they’re forcing their patients’ insurance companies to cover expenses they normally wouldn’t be responsible for, increasing premiums for everyone.
Falsifying Service Dates
This dishonest practice entails falsely claiming that a service was supplied to a patient on two days when it was only provided once. To take advantage of the fact that each “office visit” is typically seen as a specific billable service, it is common practice to alter the service date. The service date on the claim form must coincide with the date of service documented in the patient’s medical record.
Medical identifying theft
A sort of insurance fraud known as “medical identity theft” occurs when a person uses another person’s personal identifying information to get medical treatment or reimbursement for it. Identity theft targeting doctors can lead to the filling of fraudulent prescriptions, the unnecessary referral of patients for unnecessary treatments or supplies, and the billing for services that were never rendered. Dental offices should secure their patients’ and doctors’ personal information to avoid it from falling into the wrong hands.
How to avoid fraud
It’s an unsavoury environment, yet we manage to run modest businesses and employ friends and family. We need to keep our money and good names to ourselves. Though most dentists lack business management training, we must be prepared to safeguard our staff and our businesses. It’s possible to get going quickly and cheaply. This means that you can:
- Learn to recognize potential problems with your financial practices by reading up on the subject. The variety and accessibility of apps that track your account activity will astound you.
- Mind the staff. Recognize the presence of family issues, financial difficulties, etc.
- Make good use of the information in your management systems’ reports. Learn more about the state of your company with the help of timely alerts and insightful trends.
- Get professional help from CPAs, attorneys, trainers, and consultants if you suspect fraud.
- Conduct thorough screenings of all prospective staff.
Dental Billing Solution Dental Revu
Most dentists today will accept dental insurance in order to entice new patients. But they have no idea how complicated it is to deal with dental insurance billing. Identifying the ways in which a dental billing company differs from a dental administrative group will help you choose the best method of collecting insurance payments. Dental Revu is able to submit insurance claims on your behalf without any mistakes and chances of fraud. By virtue of our extensive background in assisting dental offices in processing dental billing. We know directly how much more effective they are when employees have a solid understanding of the material. Insurance payouts and other benefits can be raised if you invest in the full process.