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, as much as 3% of the total spending on health care 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, and 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.
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 copayment and deductible.
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.
That depends on whether you are using an in–network or out-of-network provider. While the latter are not bound by the insurance contract and therefore can charge whatever they want, the former cannot charge 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.).
If you’ve fallen victim to dental insurance fraud or are aware of it – or for fraud prevention – you can report dental insurance fraud via your state fraud abuse hotline (may or may not be anonymous) or an anonymous tip line of your insurance provider (most providers offer tip lines).
Depending on the severity of the fraud, the dentist that defrauded you can be subjected to fines, loss of license, or even a prison term.
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), most of all 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.
Not only patients should be aware of dentist fraud – dentists themselves are subject to certain risks. The common cases of fraud on behalf of patients would include:
Dental fraud may also be perpetrated by the patient’s care provider, which is why – as a dentist or an owner – you have to make sure that you always use the right coding, list correct treating dentists on a claim, and never alter dates of service.
Oleksandr is an expert in deep research. He covers various insurance topics across verticals, adopting to every local law.