Fraud and abuse in dentistry
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Fraud and Abuse in Dentistry. Definition. Fraud is the intentional perversion of truth in order to induce another to part with something of value, or surrender a legal right.

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Fraud and Abuse in Dentistry

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Fraud and Abuse in Dentistry


  • Fraud is the intentional perversion of truth in order to induce another to part with something of value, or surrender a legal right.

  • Stated another way, fraud is“making false statements or representations of material facts in order to obtain some benefit or payment for which no entitlement would otherwise exist.”

  • Note: Intent based, and acting knowingly and willfully.

Types of Fraud in Dentistry

  • Billing for services or products not provided

  • Billing for unnecessary services

  • Billing for services provided by unqualified or unlicensed clinical personnel

  • Knowingly billing for inadequate or substandard care.

  • Filing false claim reports

  • Misrepresenting the nature of services rendered

  • Advertising/issuing coupons/discounts that are not ‘real’

  • Waiver of insurance co-payments

  • Soliciting/receiving or offering/paying remuneration to induce referrals


  • Abuse is “any practice that, either directly or indirectly, results in unnecessary costs.”

  • Abuse is acting with knowledge, or in deliberate ignorance, or reckless disregard, of the truth or falsity of information.

Types of Abuse In Dentistry

  • Failure of follow clinical guidelines or standards of care.

  • Providing unnecessary or substandard care.

  • Violation of participation agreements

  • Making false statements or representations

  • Providing insufficient documentation to support claim for reimbursement.

Moral Relevance

When acting fraudulently or abusively, the dentist would be violating the following ‘rules’ of morality:

  • “do not deceive”

  • “do not cheat”

  • “do not disobey the law

  • “do not fail to do your duty”

What isNOT Fraud and Abuse

  • Mistakes

  • Innocent Errors

  • Good faith interpretations

  • Good faith reliance on professional advice.

Consequences of Being Found Liable for Fraud and Abuse in Dentistry

1. Criminal penalties and fines.

  • Fines of up to $250,000

  • 5 years in federal prison/violation

  • Life sentence for patient death

    2. Civil fines

  • Fines of $5,000-10,000/occurrence

  • 3x the amount claimed in damages

    3. Administrative fines and penalties

  • $10,000-50,000/occurrence

  • Mandatory and permissive exclusion from practice.

Collateral Consequences

  • Licensure issues

  • Community trust

  • Financial loss

  • Mobility

  • Office morale and spirit

  • Personal reputation

Cost of Fraud and Abuse

  • Some sources estimate the dollar cost of fraud and abuse to be 10% of our health care budget.

  • This would mean approximately $200 billion of our current $2.0 trillion health care budget.

  • Dentistry’s share would be approximately $6 billion of our $60 billion component of health care spending.

Shift in Enforcement Environment

1. Department of Justice’s #2 priority.

2. “Health Insurance Portability and Accountability Act of 1996” (HIPAA):

  • provided massive increase in funding for enforcement

  • mandated cooperation among agencies

  • expanded scope of fraud/abuse statues to cover all government payers

  • expanded jurisdiction to reach fraud/abuse against private payers.

Federal Resources To Fight Fraud and Abuse in Health Care

  • FY 98 funding = $175.6 million

  • HIPPA requires a high level of cooperation among federal fraud fighting agencies.

  • Today, 551 US attorneys and FBI agents are dedicated to investigating and combating health care fraud; this compares to 346 in 1996 and 112 in 1992.

  • FBI handled 2,700 cases in 1998, compared to 591 in 1992.

Results of Increased Enforcement

  • Since 1992, criminal fraud convictions have increased by more than 400%.

  • In 1997, the government recovered $1.2 billion in criminal fines, civil settlements, and administrative penalties.

  • $968 million was returned to the Medicare trust fund.

  • In 1997, 530 suits were filed under the False Claims act alone, generating $625 million in returned funds to the US Treasury.

Increased Enforcement(continued)

  • At the end of 1998 there were 3,471 civil matters pending of which 161 had been filed during the year, an increase in one year of 200%.

  • In 1998, 3,021 individuals and entities were excluded from participation in federal health care programs--an increase of 11% from 1997 and 93% from 1996.

  • In 1998, $480 million was recovered in civil settlements, judgments, and administrative actions.

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