How NOT to commit dental insurance fraud!

Did you know that when the Health Insurance Portability and Accountability Act of 1996 (HIPAA) was finalized in 2003, one of the standards was Electronic Transactions and Code Sets.  In short, you can only bill for the procedure you actually performed.  Makes perfect sense, right? Then why are so many dental practices committing insurance fraud?

What exactly is considered insurance fraud? (This is not a complete list): 
  • Submitting for services that were never performed 
  • Misrepresenting the actual treatment rendered in an attempt to gain benefits 
  • Misrepresenting treatment dates in an attempt to gain benefits 
  • Billing insurance companies more for a service than what is charged on the patient's ledger 
  • Dental offices that do no charge or collect full-co-payment, deductibles or extend discounts and fail to disclose it on the submitted form 
  • Submitting claims for services performed by unlicensed individuals 
  • Misrepresenting the identities of patients, subscribers and/or providers
According to Dr. Paul Bornstein, former chief dental consultant for Sun Life Insurance of Canada, "fraud can occur unintentionally, or occasionally to pad a practice's bottom line, but it occurs more often than dental professionals would like to admit.  However, insurance companies are utilizing scrupulous auditors and sophisticated computer software to find fraudulent billing and collect overpayments.  In the worst case scenarios, the owners and billing staff of these practices are being charged with health care fraud, being imprisoned, fined and their licenses are being revoked."
As you already know, the ADA's CDT code book's latest update was effective January 2013 and it brought 35 new, 37 revised and 12 deleted codes to it.  In the past, this code book was updated every two years.  Beginning in 2013 it will be updated annually.  Keep in mind, your practice management software (Dentrix, EagleSoft, etc.) will usually update the procedure codes when you do software updates, however, the definitions for the codes are NOT in your software.  And according to HIPAA's standard code set (as mentioned above), any claim submitted on a HIPAA standard electronic dental claim, or ADA paper claim MUST use dental procedure codes from the version of the CDT Code in effect on the date of service.
Any time there is an update in the CDT code book, the doctor and the billing team should read the book looking for changes, additions or deletions in the descriptions of the codes to ensure you are billing correctly.  This book should not be kept locked away in a cabinet, it should be easily accessible to anyone who is posting procedures to patient accounts/ledgers.
We have found on many occasions that the doctor or hygienist rely on the administrative team to tell them which code should be billed out, but in reality, if the administrative team member was not in the operatory or does not know exactly what was performed on the patient, they could be providing the clinicians with the incorrect information inadvertently.
Training on coding updates is a great topic for one of your team meetings!  If you would like additional training or if you have any questions, please contact Amy or Michelle at 508-697-7318 or