Billing the Wrong Code can be Insurance Fraud!

When you provide a dental service to a person with dental insurance and you intend to bill the insurance company in hopes of getting payment you should be aware of what the insurance company is looking at in terms of fraudulent billing.  By definition, dental fraud is any act of intentional deception or misrepresentation of treatment facts made for the purpose of gaining unauthorized benefits.  These acts are(not inclusive):

  • Diagnosing unnecessary or incorrect treatment to get the claim paid
  • Upcoding or overcharging routine services with the hopes of higher reimbursement
  • Unbundling and billing separately procedures to the insurance  company that you don’t unbundle normally
  • Waiving deductibles and co-payments without showing the discounted amount to the insurance company.
  • Changing the dates of service on the claims to get the claim paid within the frequency limitation or to get the claim paid on the seat or prep date.
  • Filing claims for services that have not been rendered (filing a claim for a root canal that is never completed or a crown that was never seated) or worse yet filing for a service that was never done at all.

Many honest dentists commit fraud without realizing it when they instruct the billing employee to only bill the insurance company for a procedure and not collect co-insurance from the patient.  Or to bill out the routine extractions as surgical and unbundle to get better coverage.  This is misinformation that can be costly as far as fines and jeopardizing licensing and business operations.  Dentists/business owners are responsible for the actions of their employees whether they are in on the abuse or not.  

If dentists don’t have the time to audit claims for mistakes and possible fraud, perhaps a professional billing company such as eAssist, should be part of the solution to prevent these acts from happening.


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Dental Billing