“The Doctor Made Me Do It” – Insurance Fraud and Abuse

Do you know what is happening at your front desk?  

When an insurance company contacts a dental office requesting an audit on selected dental records, this must be taken seriously.

There are different issues that can trigger an insurance company to take a second look at the way your claims are going out.  Sometimes it is a disgruntled patient that is complaining about a claim that was submitted in error or incorrectly.  Insurance companies always ask the patients to report any evidence of fraudulent billing.

Another trigger is over billing of the same code that is disproportionate to other dentists in the area.  This is potential over utilization of a code that is an unusual pattern and now needs explanation.   

Some dentists have asked their staff to bill out a crown core build-up on every crown that is prepped.  The rationale is to make up for the low reimbursement rate on the crown.  If the legitimate documentation and supporting material do not support a core build-up for the crown it will be denied.  If it is noted that every crown prep from the individual practice includes a core build-up, this would raise a red flag because every crown does not need a core build-up and it must be supported by clinical documentation and evidence.

Thorough and proper patient record keeping are essential to preventing audits.   A documented diagnosis for every treatment provided plus a detailed medical and dental health history.  Oral cancer evaluations, periodontal charting , adequate diagnostic quality x-rays and clearly marked intra-oral photos along with treatment planning documents and estimates must be in the patient record.

Preventing an audit by following proper insurance billing protocols and getting the professional help in this area will save much time and money.  Having a professional dental billing company taking care of all your insurance billing needs will help you to save time and money and the headache of an audit.


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