Avoiding Fraud and Abuse Problems

Posted by on Friday, February 13, 2015

The National Health Care Anti-Fraud Association ("NHCAA") has estimated that between three and ten percent of all annual health care benefits paid nationwide are paid on fraudulent or abusive submissions.  Some fraud analysts indicate that there is a higher percentage of fraud and abuse in dentistry than in areas of medical practice.  As a result, there is potentially more scrutiny on dentistry with respect to fraudulent and abusive practices. 

Against this backdrop, and with heightened scrutiny on health care fraud and abuse, it is more important than ever for dental practitioners to be aware of how to avoid fraud and abuse pitfalls, and to know how to respond should they receive an audit or investigation from a governmental agency or insurance company. 

In order to avoid fraud and abuse pitfalls, dental practitioners should be aware of practices and conduct that are typically viewed as fraudulent and abusive.  Generally, dental fraud, like other types of provider fraud, is defined as any act of intentional deception or misrepresentation of treatment facts made for the purpose of gaining unauthorized benefits.  Specific types and examples of fraudulent and abusive practices include the following: a) billing for services not performed;  b) upcoding;  c) waiver of co-payments; d) waiver of deductibles; e) altering dates of service;  f) unbundling or improper use of codes;  g) misrepresenting patient identities; h) not disclosing the existence of additional primary coverage;  i) performing unnecessary services;  j) misrepresentation of services;  and k) using unlicensed employees.  Avoiding these practices, and ensuring that your billing staff are aware of what can constitute fraudulent actions, will be the first step in avoiding an audit or investigation.  Future blog posts will address how to respond to such audits, investigations and allegations.