Dental Insurance Fraud: When Your Teeth and Money are at Stake

A slowly but steadily growing average expenditure on dental care insurance leaves no doubt that oral health will remain the top health-related priority among Americans, followed by mental health, exercise, and diet. At the same time, around 3% of healthcare spending is caused by fraud, including dental fraud.

Billions of dollars are spent on fraudulent dental services annually, but that doesn’t mean there’s no way to avoid the traps of cunning insurance agencies and greedy dental clinics. Knowledge is power, especially so in the overcomplicated dental insurance industry, where even a tempered customer can be craftily led astray.

Whether you provide dental services or you are a client, you are likely to raise your dental fraud awareness and answer the notorious question, ‘is my dentist scamming me?’ with the help of the information below. Without any further ado, let’s dig into it.

What Is Dentist Insurance Fraud?

Dental fraud is a crime where an individual intentionally and unlawfully receives insurance money through deception, which can be done in a variety of ways both by the client and the dentist: billing for services not provided, billing for unnecessary or inaccurate services, misrepresenting dates of services, billing for a covered service when a non-covered service was performed, using a fake ID, and waiving patient’s co-payment and deductible.

Three Most Popular Cases of Dentist Fraud

  • Unnecessary treatment. Unnecessary or overdone treatment is the most famous case of dentist fraud, simply because it’s tough to spot. Since only the dentist knows what services you need and to what extent, there will always be room for shenanigans (drilling fictitious cavities, overdoing it on X-rays, or making your teeth brighter than the Sun). Even though all dental diagnoses are assigned specific codes used by both the dentist and the insurance company, the very process of diagnosis remains subjective.
  • Phantom treatment. One of the most egregious cases of dental fraud, phantom treatment, is billing for services that were never rendered. The good news is the charges for the phantom treatment will inevitably show up on your credit card – or your insurance company will notify you – so the fraud attempt won’t go unnoticed. In this case, you must be vigilant and timely dispute fraudulent charges.
  • Wrong date of treatment. Recordkeeping is paramount in dental insurance. It is fraudulent to specify any date other than the treatment’s actual date, even if no benefits are involved.

Last but not least, fraud by ignorance or accident is still fraud. Not for nothing, there are charts helping hygienists to alternate periodontal and prophy codes properly.

Can Your Dentist Charge More Than the Insurance Company Approved?

That depends on whether you are using an in-network or out-of-network provider. While the insurance contract does not bind the latter and can charge whatever they want, the former cannot set more than the maximum amount approved by the insurance company. That said, there are cases when you can be charged beyond the co-payment even by an in-network provider – for example, if your insurance doesn’t cover a particular treatment (cosmetic procedures, tooth whitening, etc.).

How To Report Dental Insurance Fraud

If you’ve fallen victim to dental insurance fraud or are aware of it (or for fraud prevention), you can report it via your state fraud abuse hotline or an anonymous tip line of your insurance provider (most providers offer tip lines).

What Happens When a Dentist Is Found To Be Committing Insurance Fraud?

Depending on the severity of the fraud, the dentist that defrauded you can be subjected to fines, loss of license, or a prison term.

Dentist Claims

If you’ve fallen victim to poor dental care – dental negligence, which includes avoidable dental pain, injuries, misdiagnosis, and extra treatment required because of negligence – you can initiate a legal process by filing a complaint within three years from the date of the negligence. 

The claim will likely take between 18 and 24 months to be settled. But that also depends on a particular case (unfortunately, some claims may last for years), whether the dentist admits or denies the fact of negligence. The amount of compensation will depend on the nature of the claim (carelessness, misdiagnosis, etc.), the longevity and severity of the injury, and the degree of the required further dental treatment.

Tips To Protect Your Dental Practice

Not only should patients be aware of dentist fraud, but dentists are also subject to certain risks. The common cases of fraud on behalf of patients would include:

  • Using a fake ID or multiple IDs.
  • Request to misreport dates so that the patient could circumvent calendar year limitations.
  • Misrepresentation of the available coverage or asking for such misrepresentation to the insurance company.

Dental fraud may also be perpetrated by the patient’s care provider, which is why – as a dentist or an owner – you must always use the proper coding, list the correct treating dentists on a claim, and never alter dates of service.

Dental Insurance Fraud: When Your Teeth and Money are at Stake 1

Oleksandr Rohovnin is a Content Marketer at Phonexa.com and an expert contributor to CoverExplore. His passion is digital marketing, innovative technologies, tech industries, and – above all – distilling vast amounts of complex information into engrossing narratives anyone can relate to. At CoverExplore, Oleksandr stokes passion for auto insurance and the automotive industry in general in every story he curates.

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