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Partnering with you to help create healthy smiles

Dental fraud — what it is and how you can help fight it

An estimated 3% of the United States’ total spending on health care is caused by fraud, according to the National Health Care Anti-Fraud Association. That may sound like a small percentage, but with dental spending projected to reach $203 billion by 2027, that means we can expect to face over $6 billion in dental fraud.

Dental fraud is “any crime where an individual receives insurance money for filing a false claim, inflating a claim or billing for services not rendered,” according to the American Dental Association (ADA). Fraud can take many forms, but it requires intent, deception and unlawful gain.

Fraud harms everyone in the dental industry. It not only drives up the cost of coverage for patients and employers, but it can also directly affect your practice. Being found guilty of perpetrating fraud can result in fines, loss of professional licenses and even jail time!

Educate yourself and your staff on how to stay on the right side of the law. The  ADA (PDF) and Delta Dental can help you, and your state’s dental board may have resources as well.

Common signs of fraud to watch out for

Because fraud requires intent and deception, there are signs that you and your staff can watch out for from patients who commit dental fraud. Stay alert for:

  • Patients who use another person’s ID or multiple IDs to obtain benefits
  • Patients who request that you misreport dates to circumvent calendar year maximums or limitations
  • Patients who misrepresent their available coverage or ask you to misrepresent care to their insurance (including concealing dual coverage)

Because fraud can be perpetrated by both patients and care providers, having clear policies can help prevent fraud before it begins. Make sure your practice prohibits the following:

  • Regular failure to collect a patient’s payment without notifying the carrier
  • Claims for covered services when non-covered services are provided
  • Recommendation of unnecessary services

Although fraud requires intent, it’s possible to commit mistakes that could unknowingly get you into trouble. It’s entirely possible to unknowingly commit fraud in an attempt to help patients who might be seeking help with their coverage. For example, waiving coinsurance costs is one example of this. In other cases, it might be a simple oversight. Common mistakes considered fraud include:

  • Listing the incorrect treating dentist on a claim
  • Coding the wrong treatment (for example, prophylaxis vs. periodontal maintenance)
  • Altering dates of service

What you can do to help protect your practice

Fraud can happen at any point in the process of providing care, accepting payment and submitting claims, but having clear, consistently applied policies for your practice can help everyone play their part in fighting fraud. Here are some general steps your practice can take.

  • Make arrangements for payment with patients prior to providing services. This includes discussing coverage and fees, especially for optional and non-covered services, so that patients fully understand what their financial obligations are.
  • Discontinue relationships with patients who don’t make reasonable efforts to pay.
  • Write out a fraud policy, including examples. Make sure that your office staff has read and signed this policy.
  • Divide the tasks related to processing payments among multiple staff members. For example, have one person accept payments and another make the adjustments in patient records.
  • As a dentist or practice owner, review the claims your practice submits. Claims are considered to be legal documents submitted with your authorization. The dentist listed is legally responsible for the accuracy and honesty of a claim, even if an office manager or other staff member submits the claim.

Here are some things you can do every month to help fight fraud.

  • Mail monthly reminders to patients of their balances and minimums due.
  • Forward large uncollectable balances to a professional collections agency.
  • Review collection and production reports each month. Make sure your bank statement and your office records agree.
  • Check the percentages on your monthly profit and loss records, as well as any year-over-year changes. For example, if supplies cost about 8% of your income a year ago and you’re spending 10% this year, find out why.

What Delta Dental does to help prevent fraud

You don’t have to combat fraud on your own. We’re proud to be your partners in working to eliminate fraud at all levels and steps of the dental care process. What we do includes:

  • Educate our clients, members, dentists and employees about fraud detection and prevention
  • Conduct clinical patient examinations to ensure that provided services meet professional standards and were correctly submitted
  • Review financial and treatment records to ensure contracts are followed
  • Report potential cases to state and federal law enforcement and cooperate with fraud investigations
  • Pursue the recovery of funds when fraud is suspected
  • Terminate contracts when fraud is confirmed

If you suspect someone is committing fraud, report it. Call Delta Dental’s Anti-Fraud Hotline at 800-526-1852. You may remain anonymous during this call.

By making sure that you and your staff stay on top of the law, having understandable and consistent policies and maintaining good relationships with paying patients, you can help keep your practice in the green and trouble-free.

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