Broker blog from Delta Dental

Tag: claims

Dental fraud — what it is and how you can help fight it

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.

Freedom to choose and other myths about visiting the dentist

3‑minute read

If you’re taking a consultative approach to selling benefits, you most likely aim to help your clients answer their enrollees’ biting benefits questions. Especially if you work with small business owners, it’s important to brush up on plan details so you’re ready to provide support when necessary.

Health insurance, both medical and dental, can be confusing. Even if enrollees understand plan basics, the details can be tough to understand – and difficult to find. So we’re going to break down three common myths about choosing a dentist, for both Delta Dental PPO™ and DeltaCare® USA plans.

Myth: Enrollees don’t have much choice, if any, in the dentist they visit.

Fact: Not true. In a PPO plan, enrollees and their dependents can visit any licensed dentist and use their plan benefits. (However, they will usually save more when they visit a Delta Dental PPO dentist.)

For DeltaCare USA enrollees, this is a myth as well. Though our copay plans feature a narrower network of dentists to choose from, enrollees have the option to select a dentist from the DeltaCare USA network. If they don’t make a selection, then we will assign them a network dentist near their home address. Enrollees can also change their selected network dentist, and changes will be effective the following month.

With Delta Dental PPO and DeltaCare USA, enrollees may have more freedom to choose their dentist than you think.

Myth: Enrollees must present an ID card when they visit the dentist.

Fact: Regardless of plan type, this is not a requirement. Enrollees can simply provide the dentist with their name, date of birth and social security number or enrollee ID to verify coverage. Or they can display ID cards from their mobile device by logging in to Online Services on

We could all benefit from going green, so encourage enrollees to take their ID cards on the go.

Myth: Enrollees need to submit claim forms for each dentist visit.

Fact: Convenience is a major advantage of visiting a network dentist. For our PPO and copay plans, enrollees do not need to file claims when they visit a dentist in their network for routine dental care. Enrollees simply visit their dentist, pay their set copayment or share of coinsurance and leave with a healthier smile.

Claim forms may apply for out-of-network, specialty and emergency care, or to get a pre-treatment estimate.

For a quick guide to answering enrollees’ benefit questions, direct your clients to our resources for benefits administrators online.

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What do you get when you mix pediatric dentistry and Georgia football?

5‑minute read

Answer: One compassionate Delta Dental claims consultant

For the second interview in our series on dental consultants, we’re shining a spotlight on Dr. Thomas Gale in our Alpharetta, Georgia office.

One part enthusiastic college football fan, one part dedicated pediatric dentist and one part collaborative Delta Dental team member, Dr. Gale is a whole lot more interesting than pop culture gives him credit for.

Let’s get to know him.

We’ll start with an easy question. How long have you been with Delta Dental? And what did you do before joining the team?

I’ve worked at Delta Dental for about five years now, and I’ve been a dental consultant the whole time. Before this I was in private practice for 20 years, specializing in pediatric dentistry.

OK, and what do you do here? What does it mean to be a dental consultant?

I’m a consultant for our DeltaCare® USA, or DHMO-type, product. Basically, a patient goes to the dentist, who submits a claim for their work, and then I evaluate the claim based on the patient’s benefits. We make sure that claims are accurate. After reviewing a detailed summary of a visit and any x‑rays, we determine whether or not coverage is applied fairly and appropriately.

I’d also say that we advocate for both providers and patients. We want them to get most out of the available benefits.

So if you had to summarize your job using an analogy, what would it be?

I’m like a dental referee. If only that applied to Georgia football!

Ouch — yes! A tough National Championship game for the Bulldogs. Speaking of challenges, what are the biggest challenges you face in your work?

One of the most common issues is incorrect codes being submitted. For instance, a claim is submitted with the wrong tooth number, or is coded as a bridge retainer instead of a crown. It’s just human error, but it can greatly impact a claim and the patient’s experience if it isn’t reviewed.

What do you like about your job? What about working at Delta Dental?

I liked owning my own practice, but at a certain point it’s refreshing to be able to concentrate solely on the clinical side of dentistry. There is also a strong camaraderie here at Delta Dental. It’s nice to have other dentists you’re working with to review cases and get opinions. It’s just been great to work here.

We like to think we’re improving people’s lives in some way every day. How do you think your team feeds into that specifically?

From my professional background, I take a real interest in the pediatric cases that I review — especially when I’m able to make an impact on claims for children who are in pain. It’s important to me that I’m able to help them get the care they need as quickly as possible. Children shouldn’t be left waiting in pain.

It’s especially important to create positive experiences for children as these may be the first dental experiences they ever have, and they’ll remember them going forward. A child with a positive perspective on dentistry is most likely going to become an adult who cares for their oral health.

That is a great point. Other than reviewing claims, how do you keep your skills sharp?

To remain a licensed dentist, which we all are, we have to do clinical coursework every year. Also, I like to think most dentists are tinkerers — we like to do stuff with our hands to keep busy. Many dentists have hobbies that require a lot of dexterity.

Do you have any of those hobbies?

Yes, I garden and I do some woodworking in my spare time. Recently, I’ve made some Adirondack chairs out of 100-year-old barn wood.

As for my coworkers, my colleague Dr. Westee plays the bass guitar. She’s pretty cool!

Going back to children’s first experiences, what is your take on dental phobias? They seem to have saturated popular culture. What’s it like to be in a profession with such a negative perception?

With phobias, parents can actually help foster positive experiences. For instance, parents should get kids in to see the dentist early and often. You don’t wait for a high fever to take a child to the pediatrician for the first time, so why wait until kids have a toothache to go to the dentist for the first time?

Make children’s initial dental experiences good ones — a simple cleaning, some tasty fluoride, a treat afterward, whatever it is! Just don’t let it be a filling or worse.

That is a great point. Now for the fun stuff. What would your former patients be surprised to learn about you?

I really enjoy mission work. I started out in 2007 in Peru, and my brother and I started a nonprofit in 2013. I’ve also been to Ecuador, but more recently I have gone to Nicaragua with a group of doctors and dentists to provide medical and dental care.

That’s so cool. Have you noticed any differences between your clinical work in the U.S. and mission work?

Yes — a profound lack of access to care. People in Peru would walk three days to see us. One of the most profound experiences I had was witnessing people cry when numbed because it was the first time they’ve not felt pain in years. That changes your outlook on some things.

On a lighter note, patients in Peru would sometimes bring their chickens with them so they didn’t get lost or stolen. Another big cultural difference.

Speaking of a lighter note, what’s your favorite bit of dental humor?

Here’s one we heard in dental school a lot — tell patients to “only brush the teeth they want to keep!”

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Expert dental claims review? Yeah, we’ve got a dentist for that.

Less than 2‑minute read

Most — if not all — major benefits carriers employ a staff of clinical experts to review claims — so it’s not groundbreaking to say that we have dentists on staff to review claims submissions.

However, would it surprise you to learn that we have nearly 50 people on staff whose names are followed by the initials DDS or DMD? While other carriers also offer consultant claims review, we consider our dental staff an integral part of our value proposition. And because we consider this so important, dental consultant review isn’t subcontracted to an outside agency or delegated to untrained staff.

Using radiographic imaging and detailed treatment descriptions, our dentists determine whether coverage for treatment is approved or in certain cases, denied. In other words, our dentists ensure that benefits are used and applied fairly.

Dr. Joseph Borg, our Director of Dental Policy says, “Our processing policies, backed by our staff of dental consultants, are beneficial to our clients and their employees because they ensure oversight of their benefits dollars — we’re making sure that services are administered and processed appropriately.”

Our dental consultants personally evaluate more than 200 claims per day, ensuring that:

  • Treatment and billing for pre-defined services (e.g., crowns, bridges and periodontal surgery) are appropriate and meet Delta Dental’s stated clinical guidelines.
  • Exceptions to frequencies and/or age limitations are made where appropriate or necessary.
  • Treatment is billed appropriately; for example, a complex service isn’t “unbundled” into a variety of separate codes.

Dr. Thomas Gale, a dental consultant in our Alpharetta, Georgia office, notes, “We want enrollees to get the most from their benefits — the care they expect, the care they require and the care they’re charged for.”

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