Dental fraud and abuse

What is dental fraud and abuse?

• Fraud is any act of intentional deception or misrepresentation of fact made for the purpose or likelihood of gaining an unauthorized benefit. Acts of dental fraud involve three defining features: intent, deception, and unlawful gain.
• Fraud can originate from a number of sources: providers and/or consumers of care.
• Fraud and abuse, involving providers, typically involves business acts that are inconsistent with identified acceptable and legitimate financial practices and can result in additional and unnecessary costs to the insurance carrier, the group, the broker, or to the insured. It is also possible that the insured may suffer from a lack of needed care, incorrect care, or deficient care as a result.

What does an act of dental fraud look like?

• Performing services not clinically necessary or justified
• Waiver of copayment or deductible - results in a change in fees charged by the dentist, inconsistent with what the insurance carrier believes is being charged
• Unlicensed personnel performing procedures (assistants, hygienists, etc)
• Unbundling of claims - submitting several procedures separately to receive higher reimbursement
• Billing for services not performed or not completed
• Altering records or claims for the purpose of enhancing billing
• Misrepresentation of services (performing a cosmetic service but billing for a covered service)
• Misrepresentation of dates of service
• Upcoding of dental procedures - submitting a claim for a procedure that is more complex than the one actually performed

Some examples of specific dental codes that may involve acts of fraud:

• D4341/4342 - Periodontal scaling and root planing
  • Potential for fraud - If the dentist actually performs a dental prophylaxis (prophy), but files the claim for 4 quadrants of scaling and root planing.
  • Forms of fraud - Upcoding and misrepresentation of services rendered
• D0180 - Comprehensive periodontal evaluation
  • Potential for fraud - If the dentist actually performs a regular exam (D0120), but files for the comprehensive periodontal evaluation; 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.
  • Forms of fraud - Upcoding and filing for procedures not performed
• D0210 - Intraoral complete film series
  • Potential for fraud - Filing for reimbursement for D0120 when only a few intraoral films were taken.
  • Forms of fraud - Upcoding and filing for procedures not performed
• D1351 - Sealant (per tooth)
  • Potential for fraud - Filing each sealant as D2391 single surface posterior resin.
  • Forms of fraud - Misrepresentation of services rendered
• D2751 - Crown, porcelain fused to base metal
  • Potential for fraud - Filing as D2750 porcelain fused to high noble metal ("gold alloy") in order to increase claim reimbursement amounts. This also erodes more of patient's maximum benefit and increases out of pocket costs.
  • Forms of fraud - Upcoding and misrepresentation of services rendered
• D4240 - Crown lengthening is subject to possible fraud anytime gingiva may be "trimmed" to better facilitate impression, or when margin of crown is established deeper subgingivally (deeper beneath the "gumline").
  • Potential for fraud - If the acts above do not meet the clinical definition of D4240 per the American Dental Association Current Dental Terminology. This code could be improperly used for the specific purpose of increasing compensation when performing a crown.
  • Forms of fraud - Misrepresentation of services rendered and filing for procedures not performed
• D4255 - Full mouth debridement. This procedure is required when there is so much gross plaque and calculus that an exam and diagnosis cannot be performed. This should be supported by radiographic evidence of extreme subgingival calculus (tartar well below gumline).
  • Potential for fraud - This code may be submitted instead of a prophy where there is gross calculus requiring a more time consuming scaling of affected teeth, but not enough to justify a full mouth debridement.
  • Forms of fraud - Misrepresentation of services rendered, upcoding and filing for procedures not performed
• D4381 - Localized antimicrobial agents. These are pharmacological agents inserted into periodontal pockets.
  • Potential for fraud - If these drugs are used on almost every patient without proper clinical justification.
  • Forms of fraud - Performing services that may not be clinically necessary or justified so as to increase compensation.
• D7140 - Extraction of erupted tooth
  • Potential for fraud - Submitting a 3rd molar extraction at one level of tooth impaction at a greater level.
  • Forms of fraud - Upcoding and misrepresentation of services rendered

Current Dental Terminology ^© American Dental Association.

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What are we doing about dental fraud and abuse?

We have developed a program designed to significantly raise the awareness of our members, employers, brokers and network providers concerning dental fraud.

• We focus on the ability to detect possible acts of dental fraud through several departments: our claims department, as well as the Quality Improvement department as a part of our credentialing and peer review process, and our grievance review and resolution process.
• We openly communicate our program and its intent to our networks through website communications, mailings and communications through our recruiters.
• Our goal is more than detecting fraud when it occurs. Our first priority is to prevent fraud whenever we can by deterring any person who may indiscriminately consider committing such an act.
• Building a program of prevention of new acts of fraud and one that addresses acts that are committed, is an ongoing, long-term effort.

We are currently confronting suspected acts of fraud through our grievance resolution process. We take corrective action to prevent repeat violations and to protect our members. This is an important feature for our company.

What do I do if I suspect or become aware of an example of dental fraud or abuse?

We have an electronic mailbox to which either grievances or matters of suspected dental fraud and abuse can be forwarded. Upon receiving this information, we will evaluate the matter to determine if any errors, acts of potential fraud or communication mistakes have occurred. We contact the dentist concerning the matter and attempt to address and resolve the concern as quickly as possible.

Please email us at slfgriev@sunlife.com.