FYI

Have you ever waived a copayment after a patient asked you to or unbundled procedure codes because you couldn’t find the one you were looking for? Depending on the circumstances, you could be considered negligent or even convicted of fraud.

What is fraud?

Dental insurance 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.

Fraud can take many forms, but it requires intent, deception and unlawful gain. It is possible to unintentionally take action that could get you into trouble — but what differentiates fraud from negligence is intent. For example, purposefully misrepresenting information in a claim so that you, your practice or your patients receive more money is considered fraud.

Common fraudulent billing practices

There are many billing and claims habits that are fraudulent. The most common types of billing fraud are:

• Billing for services not performed or not completed. When submitting claims, it’s important to ensure that all services included in the claim were performed or completed. Avoid inflating claims, like upgrading a simple extraction to a more complex surgical extraction or reporting a routine cleaning as a periodontal deep cleaning, which is more expensive.
• Waiving deductibles or copayments. Some Delta Dental plans include deductible or maximum waivers for diagnostic and preventive services (D&P), but not all do. Similarly, although most Delta Dental plans cover D&P in network at 100%, some plans may have a lower benefit level, such as 80% or 90%, and require a patient coinsurance. Waiving these payments when required is considered fraud because the fee you billed on the claim is not the total fee you intend to collect. If patients insist that you waive these payments, you could consider offering a payment plan or denying care.
• Altering dates of service. This occurs when a claim is submitted with an incorrect date of service. A common example of this is submitting a claim for a crown on the preparation date rather than the seat/cementation date. While this may seem initially harmless, the date of service could affect coverage for patients if the treatment occurred before their plan’s effective date or before the end of their plan’s waiting period.
• Submitting a claim for treatment using a different member’s information. Always confirm that you’re submitting claims for the correct patient. The date on which a procedure is performed is connected to the patient’s medical eligibility and waiting periods. Treating one patient and intentionally submitting the claim under another patient’s name in order to have the procedure covered is fraudulent.
• Improper use of additional codes. When submitting the codes for treatments, always use the most apt code. If there’s a code for a single service like an extraction, don’t separate out each part of the procedure into codes for individual actions like local anesthesia, incisions, drainage and sutures. This is called unbundling and is not permitted.

How to report fraud

If you suspect fraud has been committed, you can call the Delta Dental Anti-Fraud Hotline at 800-526-1852 or submit our online form for reporting potential fraudulent activity. You may choose to stay anonymous when you report fraud.

After receiving reports of suspicious activity, Delta Dental will investigate. We use tips, reports and utilization analysis to look for unusual patterns that may indicate fraud and we may work with law enforcement if needed.

Why fraud prevention matters

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 network participation and professional licenses and even jail time.

For more information about fraud, visit Delta Dental’s fraud and abuse resources.