4 common dental insurance mistakes that can lead to fraud [Free Guide]

“Fraud harms everyone in the dental industry. It not only drives up the cost of coverage for patients and employers, but it can also directly affect your practice. Being found guilty of perpetrating fraud can result in fines, loss of professional licenses, and even jail time!”  -Delta Dental

Why is fraud so rampant in the dental industry?

It turns out that dental insurance fraud often comes from common mistakes made by dental teams with no intention to defraud insurance companies. When you don’t have RCM experts like those at DCS managing your insurance claims process, mistakes that appear to be fraud are more likely to happen.

This article will walk you through 4 simple mistakes that are seen as fraud, and our Dental Fraud Prevention Guide: From the Experts in the DCS Knowledge Network will give you actionable tips for how to avoid these errors at your dental business. 

Now let's get into 4 common mistakes that lead to fraud.

Mistake #1: Incorrectly listing the treating dentist 

In dental insurance, most fraud — intentional and unintentional — is committed on the claim form.

When we talk about Preferred Provider Organizations (PPOs), a dentist signs a contract that agrees to write off a certain amount of the standard service fee. This agreed-upon fee determines the patient’s total financial responsibility. This dentist is then considered in-network for that insurance payer, and bills accordingly. 

But sometimes an office has an associate dentist who provides treatment, but is not credentialed, (i.e., they’re not in-network with the insurance payer). Whenever this out-of-network dentist treats a patient, they should be listed on the claim as the treating dentist, but instead, the office’s in-network provider is put on the claim form so the treatment will qualify for the network fee.

Doing something like this is typically financially motivated, especially in instances where insurance doesn't provide out-of-network benefits. It is often viewed as helping the patient receive the best benefit available, rather than any or no out-of-network benefit received. 

For the patient, their dental plan may have a higher deductible and not pay 100% or 80% of the costs. They may pay 80% of a dental cleaning fee that’s in-network, but 100% of the treatment cost if it’s done by an out-of-network dentist.

Related: In-network or out-of-network: Pros and cons for your dental practice

Regardless of who benefits, it’s dental insurance fraud to gain network participation by listing someone other than the treating dentist as the treating dentist, because the dentist may receive funds they are not entitled to. 

Simply put, whoever is in charge of filing claims needs to be honest and accurate when filling out the ‘treating provider’ section of the claim form. Otherwise, they’re submitting a fraudulent claim.

Mistake #2: Not disclosing the treatment is due to an auto- or work-related accident

Let’s play out the following scenario to better understand how an accident-related mistake on the claim form can lead to a fraudulent claim… 

A patient comes in who has fallen in the kitchen and broken their front tooth. On the claim form, you have to disclose that the treatment is related to an accident. Dental software usually leaves this field blank by default, so you need to manually change that. 

Next, you need to state what kind of accident this was. Did it happen on the job, so it is covered by workers' compensation? Did happen in a car accident, and may be covered by auto insurance?

It’s common for a team member who doesn’t know how to manually enter that information, or who doesn’t understand the importance of it, to just send the claim off without those critical details, so they can get it paid and move on.

But an accident-related claim filed without accident information is fraudulent. By skipping over that part of the form:

• The dentist will receive reimbursement they may not have been entitled to, and
• The dental payer may be paying more than they were obligated to.

This is why it’s crucial that the details of any accident be included with the claim. The dental payer may not be liable to pay that claim until it’s first considered by medical or any other third party, such as auto insurance or workers’ comp providers.

Mistake #3: Lack of education and training on insurance claim guidelines

When common dental billing mistakes lead to fraud that can land a dentist in jail, one can’t help but wonder, what went wrong? We usually chalk it up to a lack of education and training. The dentist and their team don’t see what is wrong with these small errors and omissions on a claim form.

Related: Dental billing training: What's the most efficient way to learn?

Let’s be fair, though. If you haven’t had proper training on the large importance of these small discrepancies, how would you know about them?

Here’s a similar to Mistake #1, when we described how listing the wrong treating dentist can lead to insurance fraud. This is a real-life example — we know dental teams who have done this and unknowingly committed dental fraud… 

A locum tenens (a temporary dentist filling in for a dentist who is on vacation or out sick) substitutes for the owner-dentist, but the claim form reports that the practice owner was the treating dentist instead of the locum tenens.

This is a simple mistake made from lack of training and education. Unfortunately, the insurance company won’t see lack of knowledge as an acceptable excuse. As they see it, this is a fraudulent claim — the owner dentist should have known what was going on behind the scenes because they were being paid for the procedure.

Mistake #4: Downcoding and upcoding through incorrect codes

Coding inaccuracies can also lead to fraud within your practice. Here’s an example…

Let’s say you have a patient with a periodontal disease who comes in four times a year to have a periodontal maintenance procedure. For two of those visits, the hygienist codes a prophy treatment (a cleaning) even though a periodontal maintenance procedure was actually performed — but why?

Because the patient’s benefit plan will pay for two prophys a year and two periodontal maintenance procedures per year, but not the two additional maintenance procedures the patient requires. 

Instead of receiving no benefit coverage for those additional treatments, the hygienist reports them as the treatments that will receive benefit coverage. This is dental insurance fraud, as it leads to the dentist receiving benefits they weren’t entitled to.

Specifically, this is called downcoding. That means to report a lesser service than what was performed, resulting in the dentist being paid when they shouldn’t have been paid. 

On the flip side, there is upcoding — quite literally the opposite of downcoding.

For example, a patient comes in with an impacted tooth in the bone. Treatment requires removing bone around the tooth with a surgical bur, or sectioning of that tooth for removal. This is a routine extraction, but a surgical extraction is reported on the claim.

This is a fraudulent claim because a surgical extraction code pays at a higher reimbursement level than a routine extraction, so the dentist will receive more than they were entitled to. 

There are specific, clear lines for each procedure and treatment that every dentist and their teams should be aware of — and adhere to — when filing claims to avoid committing dental insurance fraud.

How can your dental team avoid making these mistakes? We’re here to help

All 4 of these dental insurance mistakes that lead to fraud can be avoided.

You can access our actionable tips for preventing these mistakes for free. Download our Dental Fraud Prevention Guide: From the Experts in the DCS Knowledge Network by filling out the form below. You’ll immediately receive an email for a downloadable PDF.

Is your team unintentionally committing dental insurance fraud with these mistakes?

To recap, here are the 4 common dental insurance mistakes that lead to fraud:

How will you and your team prevent these mistakes? Download our free Dental Fraud Prevention Guide: From the Experts in the DCS Knowledge Network and get the knowledge you need to maintain compliance and success at your dental business.