While most doctors would be horrified to hear that insurance fraud is being committed in their office, the truth is that many well meaning staff members are stepping over the line in the name of “the good of the practice.” While we do suggest that every doctor send his insurance coordinator to refresher courses on a regular basis, let’s look at some of the places where mistakes are being made.
- Composite fillings – While many insurance companies refuse to cover composite fillings on posterior teeth, except at the amalgam level, its fraud to bill out a composite as an amalgam. All composites should be billed to insurance companies as composites with the patient responsible for the difference between the composite and amalgam fees when the insurance companies downgrades the fee to an amalgam fee.
- Discounts – I’ve heard staff members say “we give you a discount, not the insurance company.” While this might sound just fine to patients, it is fraud to send inaccurate charges to insurance companies. If you’re discounting 20%, it needs to come off the fee submitted to the insurance company, not just the patient’s co-pay.
- Cleanings – While there have always been questions on whether to bill out a regular cleaning (D1110) or a periodontal cleaning (D4910) for a patient who has had periodontal therapy, dentists and hygienists are required to report what they actually do. The patient who does not have a healthy mouth and who requires more than the basic removal of plaque, calculus and stain should be coded as a periodontal cleaning without consideration of “how many cleanings can we get insurance to pay in a year.”
- Adjusting dates of service – We all try so hard to please our patients that it’s tempting to agree to change the start date on a procedure to either get it covered before a plan is terminated or to allow the patient to claim it on their flexible spending plan. There is however, absolutely no doubt that doing this constitutes fraud.
Billing errors – Anyone who has done insurance billing has made the occasional error. A good example is a patient who is scheduled for three restorations and the doctor only does two and keeps a watch on the third. This change of plan may not get to the insurance coordinator until after the claim has been sent…..sometimes not even till it’s been paid. It’s our responsibility to correct these errors, even if it means sending a check back to the insurance company. Not doing so constitutes fraud against both the insurance company and the patient.
