Dental fraud hurts patients, employees, and dentists alike. Many dental fraud cases are a case of false claims - for example, secretaries trying to help a patient out by billing the insurance company for another service that is covered by insurance when a different service was performed. It may seem like that scenario would help the patient by giving them a financial break, but if the dental practice gets audited or fraud is reported, then the dentist could face thousands of dollars in fees, have his or her license revoked, or have to shut down his or her practice. Then, even if the dentist didn't know fraud occurred, patients would not have a dentist to see and every person that dentist employed would be out of a job. If you suspect dental fraud as a dentist, employee, or patient, it's important you report it to the appropriate authorities immediately. Here are 12 dental fraud red flags you need to look out for.
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What is dental fraud?
Dental fraud is any act of intentional deception or misrepresentation of dental treatments in order to gain unauthorized benefits. Dental fraud has three key features: intent, deception, and unlawful gain.
Dental fraud can include the following:
- Billing for services not rendered: a patient may be billed for a check-up from the dentist, fluoride, and sealants when a dentist merely saw the patient for five minutes, which means that the patient was billed for services not received.
- Altering the dates of service: the service and the claims date should be the same because insurance companies may have a waiting period before benefits are available. An office may change the date of service to take advantage of any early deductible requirements, but that's fraud.
- Waiving deductibles and co-payments: if dentists fail to reduce fees to the insurance company when they aren't collecting deductibles and co-payments from patients are guilty of inflating fees to the insurance company. Over-billing is fraudulent and illegal. Providers may think they are helping patients by waiving these fees, but then the insurance company pays expenses that they wouldn't otherwise pay, driving up costs for policyholders overall.
- Misrepresenting services: diagnosing or billing procedures incorrectly is fraud. Changing the code to increase the reimbursement for the dentist office, increases the patient's out-of-pocket costs if their insurance policy only covers so much treatment. In one case of fraud, an insurance company noticed a dentist billing for impacted teeth instead of routine dental extractions - and that company was submitting the same radiography for each case with only the patient name changing.
- Unbundling services to charge separately or overcharging for procedures: the American Dental Association (ADA) sets billing codes for services rendered that may involve so many steps per service. Separating dental services into component parts and charging for each part - in a way that's greater than the cost of a single, bundled service - is fraud. For example, in a tooth extraction, a dentist may have to extract the tooth, elevate the flap, curettage the periapical tissue, make an incision, drain the site, and suture the socket. If a dentist charged for each of these line items, that is a fraudulent charge.
- Upcoding for routine services: according to the ADA, when a practice reports a more complex or higher-cost procedure than what was performed is called upcoding because it bypasses the insurance company reimbursement limitations, increasing the practice income. Ensure that staff is never incentivized for using certain procedure codes. In one example of fraud, the staff was asked to code services to increase revenue for kickbacks without the dentist's knowledge. An anonymous tip started an investigation by an insurance carrier and the dental practice was then monitored and questioned continually for claims submitted by the office.
Big Red Flags
As a patient, if you spot any of these practices in your dental surgery, report it. They may not be direct signs of fraud, but they are signs that something is not right in that practice:
1. They don't request your old dental records. This first one is a huge red flag because how can they treat your teeth when they don't know your teeth's history?
2. They recommend extensive work that a second opinion reveals you do not need. If your dentist starts off the bat recommending lots of expensive work, they may not have your best interest in mind.
3. They have a reputation proceeding them such as flamboyant advertising, Groupon deals, and deep discounts. If the dental practice needs to go to extremes to get business, they may just be after dollar signs. Of course, all businesses need money to operate, but it shouldn't be overly flashy.
4. They don't show you examples of past work for your procedure. When you're having something done, make sure the practice shows you before and after pictures of past patients to show you examples of their work.
5. They recommend you remove amalgam fillings, claiming they are "toxic." The FDA demonstrated these old fillings were safe. It can be dangerous to replace fillings so be cautious if you're told to replace them all. Some fillings do need replacing, but others do not.
6. They don't use American-made gear such as for crowns, veneers, inlays, fixed bridges, implants, dentures, orthodontic appliances and dental gear; it should all be manufactured in the USA.
7. They treat you like a set of teeth and not a person. You'll want a dentist who gives you a more personal treatment and at least tries to make small talk.
8. They offer free services such as a free cleaning, free tooth whitening, and other services; you may be signing up for services in a big chain, like a dental mill. You'll get something free and then they'll recommend $3,000 worth of unnecessary work.
9. They tell you that you need expensive veneers to improve teeth color.
10. They try to up-sell to you for treatments such as fluoride treatment and high-fluoride toothpaste.
11. They try to sell you night guards for "grinding." Some patients do need these but get a second opinion before splashing out since many offices prescribe mouth guards as a way of making a quick buck.
12. They tell you that you need sealants; sealants are preventative to stop accumulating plaque in crevices and pits, but they can be overprescribed.
How can I prevent fraud in my dental practice?
Doctors and business owners should be aware of anything that is going on in their name. Dental professionals need to be educated on dental fraud and abuse practice in order to know how to spot it. Dental professionals are held responsible even if they have no knowledge of each claim. If you suspect fraud, hire an attorney to advise you on the course of action.
How can I report fraud if my dentist or employer (at a dental office) is committing fraud?
Contact a trusted attorney to help you with your case. It's worthwhile and important to report fraudulent activity to the right body since dental fraud costs the government and insurance payers millions of dollars each year. Overall, good, honest practices benefit us all - after all, what good is law if no one follows?
If you suspect fraud, download our free guide:
We have over 36 years of experience helping Mississippians with their whistleblowing and qui tam cases, therefore we have created a free guide to help you identify fraud and the next steps to take when becoming a whistleblower. Click on the button below to receive your free guide.
Disclaimer: This blog is intended as general information purposes only, and is not a substitute for legal advice. Anyone with a legal problem should consult a lawyer immediately.