Fraud In Your Practice: The “Need to Know” is here


Fraud In Your Practice: The “Need to Know” is here

Insurance Fraud in Dentistry

Dental fraud is on the rise. By mid-2015, the U.S. Office of the Inspector General had examined and filed complaints against dental practices in Indiana, Kentucky, Ohio, Connecticut, Maine, Massachusetts, New Hampshire, New York, Rhode Island, Vermont and California. While some of this fraud is deliberate, some may be accidental, caused by sloppy business practices. Being aware of, and knowing how to avoid fraud, can help you keep your practice safe.

What Is Fraud?

Fraud is a “false representation of a matter of fact, whether by words or by conduct, by false or misleading allegations, or by concealment of what should have been disclosed.” Examples of dental fraud include:

  • Questionable billing, including billing for services that weren’t performed and overbilling — charging more than the service is worth
  • Coding for a more expensive procedure than the one performed or incorrect coding: Occurrences of fraud in this category may become more common after October 2015 when the new ICD-10 guidelines are implemented. Under these guidelines, the number of codes increases from 14,000 to 69,000, making coding more complex.
  • Waiver of co-payments or deductibles, or including them in the claim: Many insurance providers and Medicare require that co-payments or deductibles be paid prior to submission of claims.
  • Incorrect treatment dates on claims
  • Claims for services rendered to another patient or to nonexistent patients
  • Unnecessary services
  • Nondisclosure of other insurance coverage

Consequences of Fraud

According to the FBI, health care fraud costs the country tens of billions of dollars a year. For the practitioner, the consequences of fraud can include thousands of dollars in fines, loss of license, practice closure and jail time. When fraud occurs among staff, the effects can be financial loss, loss of patients and additional fines.

Protect Your Practice

The Centers for Medicare and Medicaid Services recommend dental offices implement a compliance program that reviews claims prior to submission. Such a program should also include an internal auditing process and routine monitoring.

With regard to staff, the American Dental Association identifies four factors that increase your risk of fraud:

  • Poor internal controls
  • Too much control limited to specific employees
  • Lack of supervision
  • Failure to pre-screen employees 

Call me, please, if you feel your practice could even REMOTELY be navigating these waters.  Your awareness of how easily fraud can occur through business practices or haphazard approaches to insurance reimbursement is of the utmost importance.