Broker blog from Delta Dental

Tag: fraud

The intelligent future of dental insurance

First, let’s set the record straight: Artificial intelligence, or AI, in the dental industry doesn’t mean your dentist will be replaced by a robot. (Although, yes, a robot dentist might be kind of awesome.)

Instead, for both dentists and insurance companies, AI technology will bring accuracy, consistency and efficiency to a new level. And the good news is that this futuristic technology is here now.

What is artificial intelligence, anyway?

While the technology is complicated, the idea behind it is simple: AI uses computer software to analyze large sets of information and find patterns in them. As it gathers more and more information, it gradually learns to assess situations and then make informed decisions or predict outcomes.

So what does artificial intelligence mean for the dental industry?

When a patient visits the dentist for to receive treatment for a dental issue, two things must occur. First, the dentist must determine the appropriate procedure and submit a claim to the insurance company. Second, the insurance company must determine whether the dentist’s claim is valid and the procedure will be covered.

For both dentists and insurers, inconsistency and disagreements during this process can cause frustration and delays, which can in turn lead to frustration and delays in treatment for your clients.

Here’s how AI can help.

AI can make quick, impartial decisions

In many cases, AI can analyze data far more quickly and accurately than a person can, and can act as a second opinion. One of the most promising applications for AI is analyzing oral imagery, or as they’re more commonly known, x‑rays.

“When dentists make diagnostic decisions, there are clear-cut rules,” said Dr. Daniel Croley, Delta Dental’s chief dental officer. “There are clinical rules that say, ‘This is decay,’ or ‘This is periodontal disease.’ However, that’s also open to some interpretation, and dentists have different levels of aggression when they want to treat disease.”

AI analyzes x‑rays to bring consistency and reliability to decision making, Croley said.

AI can help eliminate fraud

Certainly, most dentists are ethical and want to provide only appropriate treatment for their patients. Still, insurers have to watch out for those few bad actors who abuse the system to help ensure dental care remains safe, effective, available and affordable for your clients.

For questionable claims, insurance companies have teams of dentists available to review claims and the accompanying x‑rays for fraud. But the volume of claims insurers receive (Delta Dental processed more than 34 million claims in 2020), makes manually reviewing every claim for fraud impossible.

AI can help dramatically expand insurers’ ability to detect fraud. By being able to examine and compare thousands of x‑rays, AI can quickly detect abuse such as resubmission fraud, where a dentist uses the same x‑ray to submit multiple claims, and overdiagnosis. (It can also identify honest errors, such as when a dentist mistakenly submits the wrong image.)

Because AI can retain vast amounts of information and compare it instantly, Croley said, it can identify potential fraud much more easily than a person can.

“It will be able to not only to review reports like we do to determine how a certain procedure was done,” Croley said, “but it can also look at the x‑ray that was submitted with it and say, ‘Hey, this was submitted last year for another patient.’ AI will be able to recognize that and learn as it as it goes along.”

It’s for this reason that Croley believes fraud detection is emerging as one of the leading uses for AI in dentistry right now.

This ability to detect fraud quickly and accurately is a win for everyone. It protects insurance companies from dishonest dentists and conversely ensures that ethical dentists are treated fairly by insurers when they submit claims. This trust and efficiency will in turn inspire confidence for your clients.

“We only want to have quality dentists and dentists who deliver quality care in our network,” Croley said. “What AI will help us do is to monitor our network very closely, develop appropriate oversight plans and then take action when necessary. And I think how that manifests for our members is more confidence in the dentists that are endorsed by Delta Dental as network providers.”

The future for AI in dental insurance looks bright

AI is still an emerging and evolving technology, so its full promise hasn’t been realized, and there are still challenges that must be overcome. For instance, many states require a licensed dentist to be involved in any review of a dental claim.

“There’s still a lot of rules around benefit determination at the state level,” Croley said, “but once regulation starts to keep up with the technology, we may see some of that evolve from a regulatory standpoint.”

Still, Croley is optimistic about AI’s potential and what it will mean for your clients. He believes AI will enable Delta Dental to improve the quality of treatment that its dentists deliver and members receive. This in turn will increase members’ confidence in Delta Dental.

“This is what I’m excited about,” Croley said.” People trust us to do the right thing, and AI will enhance the level of trust that they have with us.”

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.

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