Common Types of Dental Fraud

Introduction - Dental fraud can take many forms. As discussed earlier, billing for non-medically necessary services or for services rendered by unlicensed individuals may be deemed fraud. Other common examples of fraud concern coding issues, the waiver of copayments and deductibles, and failing to bill insurance for covered services.

1. Common Coding Issues - The American Dental Association Code on Dental Procedures and Nomenclature (the “CDT Code”) is complex and can be deceptively manipulated to result in higher reimbursement for a dentist. Two of the most common coding-abuse practices are known as “upcoding” and “unbundling.” Upcoding is billing for a more expensive service than the one actually performed.⁴⁰ Unbundling is the practice of a doctor billing for multiple components of a service that must be included in a single fee.⁴¹ Upcoding and unbundling, as well as other forms of deceptive coding, may be deemed fraudulent under federal or state law.

a. Case Study: A West Virginia dentist was sentenced to prison after he admitted that he upcoded billings for tooth extractions by submitting claims to Medicaid that he performed complex procedures, such as extractions of impacted teeth, when he had actually performed simple extractions.⁴²

2. Waiving of Copayments and Deductibles - A dentist who accepts payment from a commercial insurance carrier under a copayment plan as payment in full without disclosing to the carrier that the patient’s payment portion will not be collected, is engaged in overbilling.⁴³ The essence of this impropriety is deception and misrepresentation; an overbilling dentist makes it appear to the commercial insurance carrier that the charge to the patient for services rendered is higher than it actually is.⁴⁴ Routine waiver of coinsurance, copayments or deductibles, where such waiver would affect the amount the insurance carrier would be pay, may be unlawful.⁴⁵ If a carrier discovers the practice, it may jeopardize reimbursement from the carrier.⁴⁶ Reasonable, good faith attempts at collection of coinsurance, copayments or deductibles should be made and documented.

a. Case Study: A New Jersey Court concluded that a dentist that submitted claims for his full fee, even though he intended to waive the copayment, constituted fraud against the insurance company.⁴⁷

3. Failing to Bill Insurance For Covered Services - As a general rule, it is the patient’s choice as to how to use their insurance benefits, but will often look to their dentist for information related to coverage and reimbursement issues. Unfortunately, some dentists use their patients’ unfamiliarity with their dental benefits to deceive the patients to pay higher out of pocket costs for covered treatments. Deceiving patients in this manner, or otherwise failing to obtain an informed waiver from each patient could constitute a violation of the law.⁴⁸

a. Case Study: In 2007, a Pennsylvania Dentist’s license was revoked by the State Board of Dentistry for deceiving a patient to issue the Dentist a personal check in the amount of $10,000 for dental services, in violation of the practice’s billing protocols.⁴⁹