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Partnering with you to help create healthy smiles

What you need to know about dental fraud

Mar 10, 2023

By Delta Dental

According to the National Health Care Anti-Fraud Association, 3% of all health care expenditures are lost to fraud. When applied to the estimated $162 billion spent on dental care in 2021, it represents $4.86 billion in fraud.

That loss increases the cost of coverage for patients and employers. And if you’re caught committing fraud, it can result in fines, loss of professional licenses and even prosecution.

What is fraud?

Fraud can take many forms, but it requires intent, deception and unlawful gain. Signs of fraud and abuse in the dental office include:
 

  • Providing unnecessary services
  • Submitting claims for covered services when non-covered services are provided
  • Regular failure to collect payments from patients without notifying the carrier
  • Incorrectly reporting dates to get around maximums or time limitations
  • Limiting the availability of appointment times when compensation is capitation-based (for example, in dental HMO-type programs)

How to fight fraud

So how can you make sure your practice isn’t committing fraud? Some tips include:
 

  • Make reasonable efforts to collect patient coinsurance/copayments. This includes creating payment plans, issuing monthly billing statements to patients, and forwarding large balances to a collection agency. You should discontinue the relationship with a patient who won’t make reasonable efforts to pay his or her portion.
  • Discuss coverage and fees with patients before treating them, especially if the procedure is optional or not covered.
  • Create a fraud policy that includes a definition of fraud. Have everyone in the office read and sign the document.
  • Separate tasks related to payments. For example, assign one person to accept payments and another to make adjustments to patient records.
  • Review collection and production reports monthly. Reconcile your collections to make sure bank statements and office records agree.
  • Check the percentages on your monthly profit and loss records, as well as any changes.
  • Use a practice management system. Your system may have reports or features to help protect your practice from fraud. 

How Delta Dental is combating fraud

Delta Dental works hard to eliminate fraud at all levels and steps of the dental care process. What we do includes:
 

  • Educating our clients, members, dentists and employees about fraud detection and prevention
  • Conducting clinical patient examinations to ensure that provided services meet professional standards and were correctly submitted
  • Reviewing financial and treatment records to ensure contracts are followed
  • Reporting allegations to state and federal law enforcement and cooperating with fraud investigations
  • Helping to recover funds when fraud is suspected
  • Terminating contracts when fraud is confirmed
     

If you think someone may be committing fraud, call Delta Dental’s Anti-Fraud Hotline at 800-526-1852. Reporting is anonymous.

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