AI Solutions for Healthcare
Unveiling Dental Fraud, Waste and Abuse: Exploring Oversight Challenges 

In the world of healthcare, the issue of fraud, waste, and abuse (FWA) is a significant concern that spans various sectors, including dentistry. Dental FWA not only undermines patient trust but also strains healthcare resources and compromises the integrity of the entire industry. This forensic AI alert blog delves into the complexities of dental FWA, shedding light on the multifaceted oversight challenges that contribute to its persistence. 

Understanding Dental Fraud, Waste, and Abuse 
  1. Fraud: Dental fraud involves deliberate deception for personal gain. This can range from submitting false insurance claims to performing unnecessary procedures for financial benefit. 
  1. Waste: Waste in dental care refers to the inefficient use of resources, such as unnecessary tests, procedures, or administrative tasks, leading to unnecessary expenses. 
  1. Abuse: Dental abuse involves practices that may not be intentionally deceptive but result in excessive costs due to overutilization or misuse of services. 
Factors Contributing to Oversight Challenges 
  1. Lack of Standardization: The dental industry lacks standardized guidelines for treatment and billing practices, making it difficult to identify clear cases of FWA. 
  1. Complex Insurance Systems: The intricacies of dental insurance systems can create confusion, allowing fraudulent claims to slip through the cracks. 
  1. Limited Resources: Many regulatory bodies have limited resources to investigate every claim, making it challenging to effectively monitor and curb fraudulent activities. 
  1. Technological Advances: Technological advancements make it easier for fraudsters to create convincing fake credentials and manipulate digital records, evading traditional oversight methods. 
  1. Fragmented Oversight: Dental services often fall under the jurisdiction of multiple regulatory bodies, leading to fragmented oversight and making it easier for illicit activities to go unnoticed. 
  1. Lack of Awareness: Patients may not be fully aware of their rights, making them vulnerable to unethical practices and allowing fraud to go unreported. 
Addressing Oversight Challenges 
  1. Collaboration: Stakeholders across the dental industry, including providers, insurers, and regulators, need to collaborate to establish comprehensive oversight strategies. 
  1. Technology Integration: Embracing advanced technologies, such as data analytics and AI (Artificial Intelligence), can help identify patterns indicative of FWA. 
  1. Education and Awareness: Educating patients about their rights and providing clear information about procedures can empower them to detect and report irregularities. 
  1. Standardization Efforts: Industry associations and governing bodies can work together to develop standardized guidelines for treatment and billing practices. 
  1. Increased Resources: Allocating more resources to regulatory bodies for investigation and enforcement can enhance oversight effectiveness. 
2023 dental investigations discovered by the Texas HHS-OIG   

In early 2023, Medicaid Provider Field Investigations (PFI) continued to examine dental providers whose billing patterns suggest possible FWA. Issues include billing for a high number of restorations (otherwise known as fillings) in children coupled with lower billing for preventive procedures, such as sealants and preventive resin restorations. In many cases, a records review indicates upcoding by the dentist to receive a higher reimbursement for a restoration when post-treatment x-rays reveal that only a sealant was placed. 

Investigators also found instances of x-rays not supporting medical necessity for placement of stainless-steel crowns (caps), unnecessary removal (extraction) of primary (baby) teeth and upcoding simple extractions by using a more expensive reimbursement code reserved for more difficult extractions. Additionally, investigations address dental providers billing for an equal number of pulpotomies (root canals) and stainless-steel crowns on primary teeth. Often dental x-rays do not show that a pulpotomy is medically necessary. 

Another concern within the Medicaid dental program arises when providers bill for services different than the ones they provided or services they did not provide. Examples include billing for x-rays not taken and performing a composite (white) restoration while billing for a stainless-steel crown. 

In late 2023, Texas HHS-OIG preliminary investigations from multiple sources focused on standard-of-care allegations involving dental providers. Concerns included inappropriate administration of sedation, discharging the patient before they fully recovered from anesthesia, billing for sedation levels the provider was not credentialed to perform, providing non-medically necessary restorations and extractions, billing for failed sedation, and abnormally high numbers of dental services billed on a single date of service. 

Recent Department of Justice conviction for fraud and efficacy issues against a Wisconsin dentist 

One example of gross patient harm and fraud stems from a Wisconsin dentist who submitted over $4 million in claims to health plans from 2015 to 2019 by purposefully breaking his patients’ teeth with a drill and then performing crown procedures. The dentist sold his practice in 2019 and the due diligence by the new owners discovered the former owner was performing more crowns than expected, which prompted an investigation. The insurance scam involved the dentist taking x-rays of the “damaged teeth” to support the medical necessity of the crown procedure. Additionally, the patients were required to pay significant co-pay for the crown procedures.  

Provider responsibility and health plan awareness 

Dental professionals must realize that they are responsible for any claims submitted from their offices, whether they even have direct knowledge of the claim.  They are liable for all information recorded in their names and can be criminally liable for it. How can doctors avoid this situation in their offices? Most doctors concern themselves with the clinical side. However, doctors should also pay close attention to the operations side and perform their due diligence. 

The battle against dental FWA is multifaceted and demands collaborative efforts from all stakeholders involved. By addressing the challenges of oversight through increased awareness, technological advancements, and policy changes, the dental industry can move toward a future with greater transparency, patient trust, and efficient resource utilization. Only through proactive measures and ongoing vigilance can the dental sector maintain its integrity and continue to provide high-quality care to patients. 

How can Codoxo help your plan identify dental providers of interest? 

Fraud Scope can reduce the amount of time, energy, and financial investment to identify dental FWA, conservatively estimated at 5% of a health plan’s annual spend for all dental claims. Identifying these claims and providers is important not only to aid in the identification of potentially fraudulent claims, but also for patient safety and the associated potential risks.  The platform’s detectors work by analyzing data for patterns, frequency, and volume of various claims across all peer groups. This analysis empowers customers to pinpoint potential FWA, as well as efficacy issues, by providing them with a comprehensive overview of claims behavior. 

When Fraud Scope users want to find crown procedure codes with the highest paid exposure, they can navigate to the Schemes page, choose Dental and Rendering, then scroll down to the Top Codes widget, enter a procedure code in the Search bar, such as CDT D2790 [Crown – full cast high noble metal], and hit Enter. The Top Codes widget returns the Total Paid Exposure for that crown procedure code, which the user can then review at the Provider, Reason, or Patient level.  

If a Fraud Scope user is researching providers with a high patient percentage or claim compositions for any crown procedures, the Query Aggregates tool allows them to search at the Rendering or Billing level for the specific CDT procedure codes, such as CDT D2740 and D2750. 

To identify dental claim lines for extractions of baby teeth, Fraud Scope users can build a Query at the line level using for the specific procedure codes D7111, D7140, D7210 and D7250 with Teeth Numbers for baby teeth, which are letters within the range of A through T. 


Office of Inspector General, Texas Department of Health and Human Services

Department of Justice, US Attorneys, Eastern District of Wisconsin