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Avoid Insurance and Billing Fraud

Paul Bornstein DMD

Sponsored by Renaissance Systems & Services



the problem
  • Fraud can occur unintentionally, or occasionally to pad a practice bottom line, but it occurs more often than dental professionals would like to admit. However, insurance companies are utilizing scrupulous auditors and sophisticated computer software to find fraudulent billing and collect on overpayments. In the worst case scenarios, the owners and billing staff of these practices are being charged with health care fraud, being imprisoned, fined and their licenses are being revoked. Don't let an innocent mistake affect your professional, financial, and personal future.
what is fraud

Current Location: Home > Fraud >

What to Look For

Tuesday, April 7, 2009

  • Submitting for services that were never performed.
  • Misrepresenting the actual treatment rendered in an attempt to gain benefits.
  • Misrepresenting treatment dates in an attempt to gain benefits.
  • Misrepresenting the teeth numbers and/or surfaces that work was performed on in an attempt to gain benefits.
  • Billing insurance companies more for a service than what is charged on the patient ledger.
  • Misrepresenting the diagnosis to justify payment for certain services.
  • Dental offices that do not charge or collect full co-payment, deductibles, or extend discounts and fail to disclose it on the submitted claim.
  • Falsifying treatment and/or financial records.
  • Billing for cosmetic services as medically necessary procedures.
  • Submitting claims for services performed by unlicensed individuals.
  • Dental offices/patients that conceal other insurance coverage that would pay for services on the claim form submitted (medical, dental and/or workman's compensation).
  • Misrepresenting the identities of patients/subscribers/providers.



IF IT IS NOT IN THE RECORD,YOU DID NOT SEE IT,YOU DID NOT DO IT,IT DID NOT NEED TO BE DONE, AND IT DID NOT EXIST-FROM A LEGAL PERSPECTIVE. In other words, if you completed a thorough exam, made a definitive diagnosis, devised a comprehensive treatment plan that addresses the pathology, obtained informed consent, and presented patients options, but then failed to record this information in the clinical record-from a legal perspective-you never performed an evaluation


If you see a fee schedule and have to try to come up with ways to get around the fee allowed in order to get what you feel to be a reasonable reimbursement, you have not signed up for an appropriate plan for your practice. Know how to pick and choose plans that fit your practice goals.


On August 17, 2000 the CDT Code was named as a HIPAA standard code set. Any claim submitted on a HIPAA standard electronic dental claim must use dental procedure codes from the version of the CDT Code in effect on the date of service. The CDT Code is also used on paper dental claims, and the ADA's paper claim form data content reflects the HIPAA electronic standard.

components of a dental code
Components of a Dental Code

1. CODE- A five character alphanumeric code beginning with the letter “D”…….

2. NOMENCLATURE- A written, literal definition of a Dental Procedure Code.

3. DESCRIPTOR- A written narrative that provides further definition and the intended use of a Dental Procedure Code.

restorative codes

D2391 resin-based composite—one surface, posterior

Used to restore a carious lesion into the dentin or a deeply eroded area into the dentin. Not a preventive procedure.

D1351 Sealant—per tooth

Mechanically and/or chemically prepared enamel surface sealed to prevent decay.



Restorative services shall be benefits when dentally necessary and when cariousactivity has extended through the dentoenamel junction (DEJ).

d1352 new code

preventive resin restoration in a moderate to high caries risk patient – permanent tooth. Conservative restoration of an active cavitated lesion in a pit or fissure that does not extend into dentin; includes placement of a sealant in any radiating non-carious fissures or pits.



  • In order to qualify for benefits the following conditions must exist:
  • Probing depths must be 5mm or greater.
  • Radiographs must show attachment loss with the appearance of reduction of the alveolar crest beyond the 1 -1 1/2mm proximity to the
  • cemento-enamel junction (CEJ).
d4341 periodontal scaling and root planing four or more contiguous teeth per quadrant
D4341 Periodontal scaling and root planing---four or more contiguous teeth per quadrant

This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic, not prophylactic, in nature. Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough, and/or permeated by calculus or contaminated with toxins or microorganisms. Some soft tissue removal occurs. This procedure may be used as a definitive treatment in some stages of periodontal disease and/or as part of pre-surgical procedures in other.

american academy of periodontology


There are many types of periodontal diseases. The following

is an overview of the most common:


As the mildest form of the periodontal diseases, gingivitis

causes the gums to become red, swollen, and bleed easily.

There is usually no discomfort at this stage.

Chronic Periodontitis

Chronic periodontitis is a condition resulting in inflammation within the soft tissues surrounding the teeth causing progressive attachment and bone loss.

It is diagnosed by bone loss on a dental X-ray, the formation of

gum pockets and/or receding gums. It is most common in

adults, but can occur at any age.

retrospective review sample language

A participating dentist authorizes DDTN to deduct from any payments due him/her such sums as DDTN reasonably determines to be properly due and owing to DDTN as a refund of payments incorrectly made to or claimed by the dentist for which the dentist has not refunded the amount due.

indictment dentist filed false claims for insurance
Indictment: Dentist filed false claims for insurance
  • They are charged with defrauding insurance companies of about $2.3 million.
  • While the indictment says Villalobos allegedly was doing work on patients in Juárez and billing U.S. insurance companies from addresses in El Paso, the charges have nothing to do with where services were provided.

False Claims Act/Qui Tam

Current developments in whistleblower lawsuits brought under the False Claims Act and other news

Monday, December 20, 2004

Massachusetts charges dental corporation with Medicaid fraud

Massachusetts has brought both criminal charges and a civil suit alleging violation of the state's Medicaid False Claims Act against a dental corporation. The False Claims Act suit alleges that DR.---------submitted phony bills for services that were never provided and "unbundled" services, charging separately for procedures that should have been billed together at a reduced cost. The Massachusetts Attorney General's Office issued a press release on December 15, 2004.



Treating provider number. If there is more than one dentist at a service office, enter

the provider number of the dentist who performed the service.

delta of illinois

3. No Balance Billing or Cost Shifting

Many enrollees realize significant out-of-pocket savings from our industry-exclusive "no balance billing" provision prohibiting network dentists from billing Delta patients for any difference between their submitted charge and the amount Delta allows (i.e., the maximum plan allowance). Enrollees only have to pay deductibles and copayments required by their employer's plan.

In addition, network dentists cannot bill Delta Dental patients for charges Delta Dental does not allow, such as "unbundled" services that should be billed as one procedure - so there's no "cost shifting" to enrollees. Enrollees know the maximum amount they'll pay and are protected from unexpected charges.

Delta Dental of Illinois has a sophisticated adjudication system that automatically compares procedures reported on claims in progress with those previously processed in claim history. When deviations are identified, claims are suspended for review by a dental auditor with expertise in dental treatment.

Many dentists unbundle (i.e., split procedures into component parts) in order to generate additional fee income. This is one of the many areas where Delta's cost management expertise pays major dividends for its clients.

All procedures affected by unbundling have been entered into a special system edit table that automatically disallows the component procedures while allowing the appropriate bundled procedure.

As the nation's premier dental benefits carrier, Delta Dental has used dental consultants representing each region of the country to develop standard processing policies. These uniform rules apply to all dentists in Delta Dental's networks so when unbundling occurs the enrollee is protected from inappropriate charges.

An important cost-savings is that Delta Dental Premier and Delta Dental PPO network dentists cannot shift these costs, i.e., balance bill, Delta patients for disallowed amounts.

cost shares

A cost-share is the amount you are required to pay for the services rendered. United Concordia pays a percentage of the dentist’s usual charge up to United Concordia’s allowance for the covered service, subject to limitations. The percentage paid and the enrollee’s cost-share depend on the type of service received. Dentists are required to collect cost-shares for certain covered services. Failure to collect cost-shares for covered services could disqualify the dentist from participating in United Concordia’s dentist network.

alabama diciplinary action

For the purposes of this section irregularities in billing shall include: reporting charges for the purpose of obtaining a total payment in excess of that usually received by the dentist for the services rendered;falsely reporting treatment dates for the purpose of obtaining payment; falsely reporting charges for services not rendered; falsely reporting services rendered for the purpose of obtaining payment; or failing to advise and that the co-payment provisions of a contract have been abrogated by accepting the payment received from the third party payer as full payment.


2012 by Date

September 13 Boston MA

September 14 Hartford CT

September 20 Long Island NY

September 21 Manhattan NY

October 25 White Plains NY

October 26 Paramus NJ

November 8 AZ BOOT CAMP

November 9 Phoenix AZ

November 29 Tampa FL

November 30 Miami FL

December, 6 Portland OR

December 7 Seattle WA

December 13 Torrance CA

December 14 Santa Clara, CA


2013 by Date

Jan 17 & 18 – Vegas Boot Camp

Jan 30 & Feb 1 – Baton Rouge, LA & New Orleans, LA ( WED & FRI )

Feb 7 & 8 – Shreveport, LA & Ft. Worth, TX

Feb 14 & 15 – 2 Day Boot Camp in Anaheim, CA

Feb 22 – FRIDAY ONLY – Charlotte, NC

March 7 & 8 – Oklahoma City, Ok & Tulsa, OK

March 15 – FRIDAY ONLY - Santa Monica, CA

March 21 & 22 – Hartford, CT & Boston, MA

April 4 & 5 – Portland, ME & Manchester, NH

April 11 & 12 – Fairfax, VA & Baltimore, MD

April 26 – FRIDAY ONLY – Philadelphia, PA

May 2 & 3 – New York Boot Camp

May 9 & 10 – Jacksonville, Fl & Orlando, Fl

June 6 & 7 – Grand Rapids, MI & Lavonia, MI

June 13 & 14 - Milwaukee, WI & Minneapolis, MN

June 20 & 21 – Kingston Plantation, SC Boot Camp


Sept 18 & 20 – Little Rock, AR & Houston, TX ( WED & FRI )

Sept 26 & 27 – Chicago Boot Camp

Oct 3 & 4 – Louisville, KY & Cincinnati , OH

Oct 10 & 11 – Columbus, OH & Indianapolis, IN

Nov. 7 & 8 – Atlantic City Boot Camp

Nov. 13 & 15 – Seattle, WA & Portland, OR ( WED & FRI )

Dec. 5 & 6 – Tampa, FL & Longboat Key, FL

Nov. 29 – FRIDAY ONLY – St. Louis, MO

Dec 12 & 13 – San Francisco, CA Boot Camp