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Delta Dental fraud and abuse

Fraud and abuse

How to fight fraud, identity theft and abuse in your practice.

Fraud and abuse

Only a small percentage of providers or consumers commit healthcare fraud, but that small percentage can have a big impact. Learn how to avoid fraud and identity theft in your practice.

Fraud not only drives up the cost of dental coverage for your patients, it can directly affect your practice. Understanding fraud can help you keep your practice safe.

  • Health care fraud is a federal offense and carries a federal prison term of up to 10 years in addition to significant financial penalties. [United States Code, Title 18, Section 1347]
  • Mail fraud includes health care schemes that use the U.S. mail (such as mailing claims or receiving checks). Mail fraud can be charged in addition to other health care fraud charges.
  • The IRS works with other federal agencies that are investigating health plan fraud to establish whether tax violations should be added to the federal law violation(s).
  • Dishonest providers risk patients’ health by performing unnecessary or unsafe dental procedures simply for financial gain.
  • Patients’ benefits can be depleted as a result of fraud, leaving patients without benefits when a real necessity for dental services arises.

The following are signs of fraud that can occur in a dental office setting:

  • Routine failure to collect the patient’s full payment or share of cost without notifying the carrier.
  • Concealing other available coverage.
  • Misreporting dates to circumvent calendar year maximums or time limitations.
  • Submitting claims for covered services when non-covered services are provided.
  • Providing unnecessary services.
  • Patients who use another person’s ID to obtain benefits.
  • Limiting the availability of appointment times when compensation is capitation-based (i.e., in dental HMO type programs).

Learning about fraud is a great start. You can also:

  • Be sure to make reasonable efforts to collect patient coinsurance/copayments. Reasonable efforts include:
    • Payment plans: Making arrangements with patients for monthly payments, for example, or offering the option to pay by credit card.
    • Billing statements: Mailing monthly reminders of the balance and the minimum amount due.
    • Collections: Forwarding large, uncollectable balances to a professional collection agency.
    • Discontinuing the relationship with a patient who will not make reasonable efforts to pay his or her portion.
  • Discuss coverage and fees with patients before treatment, especially for optional or non-covered services, so that they fully understand their financial obligations.
  • Write out a fraud policy, including what you consider to be 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 in patient records.
  • Review collection and production reports monthly. Reconcile collections to make sure your bank and office records agree.
  • Check the percentages on your monthly profit and loss records, as well as any changes. For example, if dental supplies cost about 8 percent of your income last year, and you’re spending 10 percent this year, it is important to investigate the increase in spending.
  • Use your practice management system. It may have built-in reports or features that can help you protect your practice from fraud. Ask your vendor about what's available.

If you suspect that fraud has occurred, contact us. You can remain anonymous.

Your patients can also be at risk for medical identity theft, which can lead to their benefits being depleted – leaving them without benefits when they need them. 

Here's how to prevent identity theft in your practice:

  • Request to see a photo ID, such as a driver’s license, when a new patient completes the forms typically requested of new patients.
  • Compare the photo ID with any enrollment document or dental benefit ID card the new patient may present.
  • Keep a copy of the photo ID in the patient’s folder.
  • Check the patient’s eligibility status online. The eligibility page provides the enrollee’s and family members’ names and birth dates, and the family members’ relationships to the enrollee. This information may be useful for comparison with other information the new patient provides.

We use various processes to help us uncover fraudulent behaviors and prevent fraud from driving up the cost of our plans, including:

  • Reviewing financial and treatment records to help ensure contracted dentists abide by the terms of their contractual agreements, including charging patients and Delta Dental appropriately and reporting claims accurately.
  • Conducting clinical patient examinations by independent dentist consultants, who provide unbiased opinions not only on whether services meet accepted professional standards, but also whether dental services have been provided as submitted for payment.
  • Educating our clients, enrollees, dentists and employees about fraud detection and prevention in online and printed newsletters and on our web site.
  • In some cases, pursuing recovery of funds in instances of suspected fraud.
  • Terminating the Delta Dental participation agreements of dentists who commit fraud.
  • Reporting potential cases to state and federal law enforcement personnel and cooperating with fraud investigations, including those conducted by state dental boards, postal inspectors and the FBI.