Fraud accounts for an estimated 3% of the United States’ total spending on health care, according to the National Health Care Anti-Fraud Association. That may sound like a small percentage, but with dental spending in the United States projected to reach almost $200 billion by 2030, that means over $6 billion in dental fraud that year.
Dental fraud is “any crime where an individual receives insurance money for filing a false claim, inflating a claim or billing for services not rendered,” according to the American Dental Association. Fraud can take many forms, but it requires intent, deception and unlawful gain.
Fraud harms your business and your clients. It drives up the cost of coverage for your clients and their employees in the form of higher premiums. Every year, the average family in the United States spends an extra $400 to $700 on increased premiums because of fraud.
Common signs of fraud to watch out for
Because fraud requires intent and deception, there are signs to watch out for. Encourage your clients to instruct their employees to check their Explanation of Benefits statements and look out for dental offices that:
- Submit claims for covered services when non-covered services are provided
- Recommend unnecessary or expensive services when simple services will suffice (for example, recommending a crown when only a filling is necessary)
- Report inaccurate treatments to the insurance company (for example, prophylaxis vs. periodontal maintenance)
- Misrepresent dates of service to the insurance company
- Fail to disclose insurance coverage to their patients
- Refer patients to specialists when treatment is not needed
It’s entirely possible for dentists and staff to find themselves on the wrong side of the law after an attempt to help patients who might be seeking help with their coverage. Waiving coinsurance costs is one example of this. In other cases, it might be a simple oversight. Common mistakes considered fraud include:
- Listing the incorrect treating dentist on a claim
- Coding the wrong treatment (for example, prophylaxis vs. periodontal maintenance)
- Altering dates of service
Fraud can also be perpetrated by dentists’ patients. Ask clients to let their employees know that the following actions are considered fraud.
- Using another person’s ID or multiple IDs to obtain benefits
- Requesting that dentists misreport dates to circumvent calendar year maximums or limitations
- Misrepresenting available coverage to dental staff or asking them to misrepresent care to the insurance company (this includes concealing dual coverage)
- Adding individuals to a policy who are not eligible dependents or family members
Finally, employers can find themselves on the wrong side of fraud law as well. Encourage clients to avoid:
- Allowing ineligible people to enroll in coverage
- Making inaccurate statements that can reduce workers’ compensation premiums. Such statements include misclassifying employees, underreporting employees, underreporting payroll, reporting full employees as independent contractors and misrepresenting the name under which your company does business.
What you can do to help protect yourself and your clients
Fraud can happen at any point in the process of providing care, accepting payment and submitting claims. Dental offices with clear, consistently applied policies can help everyone play their part in fighting fraud. Here are some general tips that your clients’ employees can keep in mind as they choose their dentists.
- Request a pre-treatment estimate from dentists. This is a free service available to Delta Dental PPO™ and Delta Dental Premier® members. DeltaCare® USA members should review their benefit booklet for a list of covered services and applicable copayments.
- Discuss coverage, fees and payment prior to the dentist providing services, especially for optional and non-covered services. This way employees will fully understand what their financial obligations are prior to accepting service.
- Ask dentists if they have written anti-fraud policies and if their office staff has read and signed these policies.
To help clients’ companies avoid fraud, you can also:
- Refer clients to the “Fight Fraud” flyer (PDF) as an educational aid
- Encourage clients to implement a clearly defined anti-fraud policy and have employees sign it
- Encourage clients to set up internal controls and segregate duties (for example, ensuring different sets of employees have access to plan assets and records, rather than putting one person in charge of everything)
What Delta Dental does to help prevent fraud
You don’t have to combat fraud on your own. We’re proud to be your partners in working to eliminate fraud at all levels and steps of the dental care process. What we do includes:
- Educating our clients, members, dentists and employees about fraud detection and prevention
- Conducting clinical patient examinations to ensure that provided services meet professional standards and were correctly submitted
- Reviewing financial and treatment records to ensure contracts are followed
- Reporting potential cases to state and federal law enforcement and cooperate with fraud investigations
- Pursuing the recovery of funds when fraud is suspected
- Terminating contracts when fraud is confirmed
If you suspect fraud, report it. Call Delta Dental’s Anti-Fraud Hotline at 800–526-1852. Provide this number to your clients and encourage them to do the same. Callers may remain anonymous if they choose.