Although committed by only a small number of patients and health care providers, health care fraud amounts to a $68 billion a year business that increases the cost of health and dental insurance for everyone. In order to protect your family’s access to affordable dental care, it is important to understand what constitutes dental insurance fraud and to take action if you notice the warning signs.
What Is Fraud?
Fraud is an intentional act in which the patient or health care provider provides false or misleading information to an insurance carrier in order to obtain benefits or reimbursements that they are not entitled to receive. If detected, the repercussions for committing insurance fraud can be severe and impact those directly involved as well as those who reasonably should have known about the fraudulent activity.
Examples of Dental Fraud:
In some instances, the fraud is easy to detect, such as submitting a claim under a false identity. In other cases, it is much more subtle and can be difficult to identify, especially for the consumer who may not be familiar with medical billing practices. The following are examples of some of the most common fraudulent practices:
- Your dentist bills the insurance company for services that were never performed or that have not been completed yet.
- The dentist performs the same procedure, such as an X-ray, several times because of their own error and bills for each procedure.
- The dentist bills the insurance company for a more extensive procedure than was actually performed. For example, the dentist bills for a root planing and periodontal scaling when only a basic cleaning was performed.
- The dentist waives the required co-payment or deductible. While these waivers may seem like a nice gesture on the part of the dentist, they do skew the overall cost structure of the insurance plan.
- The dentist submits a claim using an altered date of service. This can result in a procedure being covered when the patient is still in a waiting or ineligibility period.
- The dentist uses improper billing codes when submitting the claim. The most common form of this type of fraud is a process known as unbundling in which the dentist submits the claim using multiple codes to describe the service when a single billing code is sufficient.
- The dentist fails to disclose the existence of additional insurance coverage.
- The procedure is billed under the name of a health care provider other than the one who performed the procedure.
Often times, there are simple mistakes made or clerical errors which your dentist may not be aware of.
What You Can Do:
Most dental insurance carriers will send you a notice of payment or an explanation of benefits whenever a claim is paid. You should review the information to ensure that the service date, the type of service performed, the name of the health care provider, and the amount being charged appears correct. If anything seems incorrect, you should contact your insurance carrier as soon as possible.
This guest post was provided by Brytan and Associates, Inc., a company specialized in investigating dental fraud on behalf of the dental practice that can help ascertain if there is a problem and how to correct it.