Insurance fraud costs Americans more than $80 billion per year in higher premiums, according to the Coalition Against Insurance Fraud. Insurance fraud happens when an insurance company is deceived in order to collect money for someone who is not entitled to receive the money. This is against the law in every state, and health care fraud also falls under federal laws. In most of the United States, fraudulent insurance claims can be either a felony or a misdemeanor, depending on the nature and extent of it.
Your dental practice can accidentally commit fraud, and it’s more common than you would think. In most instances, ignorance is no excuse when it comes to committing fraud. In order to avoid the small mistakes that could cost you your license and practice, let’s review the following errors in billing.
Listing the Treating Dentist Incorrectly
To determine the fees for services that are the patient’s responsibility, the dentist signs a contract with a Preferred Provider Organization (PPO). This is an agreement to write off a certain amount of the standard fee for a service that is provided. It is fraudulent if you list the owner dentist as the dentist who treated the patient in question when it was done by an associate dentist who is not in-network with the insurance payor. Whether a provider is in-network or out-of-network affects how benefits are paid to the dentist.
If the dentist receives funds he or she is not entitled to receive, it is fraud. There are different scenarios in different states when it comes to who to list on the insurance claim as the treating provider. As a result, whoever is in charge of filing insurance claims in your office needs to be 100% correct when completing the ‘treating provider’ section on the claim form.
Accident on Dental Claim Form Becomes Fraud
If a patient comes into your dental practice and has broken a tooth due to a fall at home, you have to disclose the treatment is related to an accident. It is also important to specify whether the accident was workers compensation, an auto accident, etc. These specifics determine the type of reimbursement paid to the dentist.
It also may require it to be considered by medical or another third party before payment. Some dental programs will default and leave critical information blank. Unless someone knows to manually go into the program and change it.
Lack of Education and Training Can Lead to Potential Fraud
The most common billing mistake can lead to fraud landing a dentist in prison. Proper training is essential to preventing even the smallest of errors on a dental claim form. Remember, ignorance is not an excuse. For example, recording the name of the treating doctor as the owner of the dental practice when a locum tenens was filling in could be determined as insurance fraud. The owner of the practice needs to have an interest in all areas of the practice at all times to ensure proper procedures are being followed.
Down-Coding and Up-Coding
Inaccuracies found in coding on an insurance claim can also lead to fraud. Down-coding is reporting a lesser service was performed, which resulted in the dentist getting paid something he should not have been entitled to receive. On the other hand is a procedure called up-coding. This is reporting a procedure paid at a higher reimbursement level than what was actually performed, in order to be reimbursed more money from the insurance provider. Every dentist needs to take note and be aware of these mistakes.
Know the Rules
Education is power. It can be what saves your dental practice huge problems due to common, small mistakes. You and your dental team need to be educated and trained on the rules and regulations of insurance claim submissions and coding. This type of work is extremely tedious and meticulous. But it is essential to do it correctly to prevent the dentist/owner from losing their license or going to prison. Make certain your team is up-to-date on all the best practices to prevent common claim submission errors.
Most insurance companies do not volunteer this type of information. You must request a processing manual from the company. It will include all you need to know about the rules for submitting insurance claims correctly. There are other very simple actions of a well-intentioned dentist/owner to inadvertently commit insurance fraud. In order to avoid these types of instances and others, you must know what is in the PPO contract. Lack of knowledge can lead to very serious consequences. Take the time to learn the rules!
Consider contacting the professionals at PPO Negotiation Solutions for help. Hundreds of dental practices trust them. Their mission is to enrich your dental practice by increasing revenue and understanding. They have 30 years of experience in the field of PPO negotiations and participation. They can assist you in streamlining your daily processes. Take their complimentary assessment or schedule a consultation today!