Dental Fraud, Waste and Abuse:A Billion(s) Dollar Problem
According to the National Health Care Anti-Fraud Association of the $250 Billion spent on dental care procedures annually nationwide, an estimated $12.5 Billion (or 5%) is lost to dental fraud, waste, and abuse.
While this seems like a small percentage, this harms everyone in the dental industry. It not only drives up the cost of dental coverage for patients and employers, it can also affect the dental practice.
Examples of dental fraud, waste and abuse include, but are not limited to:
1. Billing for services not rendered
2. Performing services not clinically necessary or justified
4. Misrepresentation of service
5. Misrepresentation of the provider of the dental service
6. Dental procedures performed outside their scope of practice (assistants, hygientists, etc.)
7. Altering dates of service, records or claims for enhanced billing
9. Misrepresenting patient identities
10. Not disclosing the existence of additional or primary coverage
Examples of some specific dental codes that may involve acts of fraud:
1. Upcoding and misrepresentation of services rendered
a. D1351 – Sealant (per tooth)
i. Potential for fraud if filing sealants as one surface resin-based composite, D2391. A typical upcoding error for dentists is billing for a restoration after placing only a sealant or preventive resin. While Current Dental Terminology (CDT) defines a preventive resin restoration as “a conservative restoration of an active cavitated lesion in a pit or fissure that does not extend into the dentin,” a restoration is “used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not a preventive procedure.” Hence, procedures billed as restorations must be for decay into the dentin demonstrated on an x-ray; simply sealing a surface to prevent decay should not be billed as a restoration
b. D4341/D4342 – Periodontal scaling and root planning
i. Potential for fraud if the dentist actually performs a dental prophylaxis (prophy) D1110, but files the claim for scaling and root planning
c. D2751 – Crown, porcelain fused to base metal
i. Potential for fraud if the dentist files the claim as D2750, porcelain fused to high nobel metal (“gold alloy) to increase reimbursement amounts
d. D7140 – Extraction of erupted tooth or exposed root/D7210 – extraction, erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperisoteal flap if indicated
i. Potential for fraud if the dentist submits extraction at one level of tooth impaction at a greater level
2. Upcoding and filing claims for procedures not performed
a. D0180 – Comprehensive periodontal evaluation
i. Potential for fraud if the dentist actually performs a regular exam (D0120) but files a comprehensive periodontal evaluation, D0180; a more extensive exam that should involve periodontal probing and charting of each tooth, evaluation of the patient’s oral and medical history as related to treatment of oral problems and oral cancer evaluation.
b. D0210 – Intraoral complete film series
i. Potential for fraud if files reimbursement for D0210 when only a few introral films were taken.
Be Aware – Recent Dental Civil and Criminal Enforcement Cases:
- March 15, 2022— A Wisconsin dentist was convicted on March 10 of multiple counts of fraud and making false statements, according to a press release from the U.S. Attorney’s Office of the Eastern District of Wisconsin. The dentist reportedly used his drill to damage patients’ teeth so he could bill insurance for crowns instead of fillings.
- April 27, 2022 — California dentist Dr. Aamir Wahab, Washington physician Dr. William Washington, and Utah Jazz assistant coach Keyon Dooling were arrested and charged with conspiracy to commit healthcare fraud and wire fraud, according to a press releasedated April 27 from the U.S. Attorney’s Office for the Southern District of New York. The Utah Jazz placed Dooling on administrative leave following his arrest.
- May 3, 2022— A dentist and two others have been added to the long list of people charged by the U.S. Department of Justice (DOJ) for their alleged roles in a $5 million plot to defraud the National Basketball Association’s (NBA) benefits plan.
- May 9, 2022— A Maryland dentist pleaded guilty to conspiracy to commit mail fraud and healthcare fraud in a case involving at least $1.2 million in Medicaid fraud, according to a press release from the U.S. Attorney’s Office, District of Maryland.
- National Health Care Anti-Fraud Association, https://www.nhcaa.org/
- Centers for Medicare & Medicaid Services, https://www.cms.gov/Outreach-and-Education/Look-Up-Topics/Fraud-and-Abuse/Fraud-page; https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/WebBasedTraining
- American Dental Association, https://www.ada.org/resources/practice/legal-and-regulatory/fraud-and-abuse
- Medicaid compliance for the dental professional, https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/Medicaid-Integrity-Program/Education/Dental-Resources
- Office of Inspector General, https://oig.hhs.gov/compliance/physician-education/fraud-abuse-laws/
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