Dental Fraud: A $12.5 Billion Dollar Problem

People often see dentists as professional, caring, ethical and honest individuals. However, there are employees and some dentists out there that can tarnish this image. An emerging issue that is growing is fraud in the dental practice.  According to the National Health Care Anti-Fraud Association, of the $250 billion spent on dental care procedures annually, an estimated $12.5 billion, or 5%, is lost to dental fraud and abuse.

What is dental fraud and abuse? According to Dental Economic, by definition, dental fraud is any act of intentional deception or misrepresentation of treatment facts made for the purpose of gaining unauthorized benefits. Acts of dental fraud contain three defining features: intent, deception, and unlawful gain.

What are some fraud scams? Knowing the signs of fraud that can occur in a dental office setting could save your practice. The list includes, but is not limited to, billing for services not rendered, misrepresenting dates of service, waiving of deductibles and/or co-payments, misrepresentation of services, unbundling service charges, overcharging or upcoding routine services or diagnosing unnecessary or incorrect treatment.

What are some consequences of being found liable for fraud and abuse in dentistry?

You could face criminal penalties and fines, prison time, civil fraud penalties, and loss or suspension of a professional license. You should also be aware that consent orders and criminal proceedings are a matter of public record.  Fraud can destroy your practice and your reputation.

Dental professionals must realize that they are responsible for any claims are submitted from their offices, whether or not they even have direct knowledge of the claim.  They are liable for all information recorded in their names and can be criminally liable for it. How can doctors avoid this situation in their offices? Most doctors concern themselves with the clinical side. However, doctors should also pay very close attention to the operation side and do their due diligence. Some suggestions from Delta Dental include writing out a fraud policy and having the staff review and sign on a routine basis. Another suggestion would be to separate tasks related to payments between your staff. Doctors can educate themselves so they can conduct audits on staff or hire an outside person that can perform periodic audits. Also, proper staff training can save you a headache in the long run with emphasis on fraud and proper documentation.

Ignorance is absolutely no excuse and there could be repercussions that can be severe, including losing your license.

What should you do if you suspect fraud?  Dental fraud can be reported to the insurance company, state insurance fraud departments, state department board Office of Inspector General, or your local authority. Fraud can also be reported under the False Claim Act, a federal law that imposes liability on persons and companies who defraud governmental programs.

How can Pharmacists Mutual help should you find yourself in this situation?

Pharmacists Mutual offers optional coverage for Employee Dishonesty that can be attached to your businessowners policy. In addition, if you find your license is up for review by the Dental Board, your dental liability policy has coverage up to $50,000 for defense costs. Sources:

— Erin Schroeder | Compliance Specialist