Protect Your Practice from Fraud

Only a small percentage of providers or consumers commit healthcare fraud, but that small percentage can have a big impact. Consider this: the U.S. spends more than $2 trillion on healthcare annually. At least 3 percent of that spending — or $68 billion — is lost to fraud each year. 1

Fraud not only drives up the cost of dental coverage for your patients, it can directly affect your practice. Understanding fraud can help you keep your practice safe.

Sometimes fraud comes in predictable forms and other times it is less obvious, but fraud always leaves traces. Learn more about fraud and how to prevent it.

Know the Signs of Fraud

The following are signs of fraud that can occur in a dental office setting:

  • Routine failure to collect the patient’s full payment or share of cost without notifying the carrier
  • Concealing other available coverage
  • Misreporting dates to circumvent calendar year maximums or time limitations
  • Submitting claims for covered services when non-covered services are provided
  • Providing unnecessary services
  • Patients who use another person’s ID to obtain benefits
  • Limiting the availability of appointment times when compensation is capitation-based (i.e., in dental HMO type programs).

How Delta Dental Works to Prevent Fraud

We use various processes to help us uncover fraudulent behaviors and prevent fraud from driving up the cost of our plans, including:

  • Reviewing financial and treatment records to help ensure contracted dentists abide by the terms of their contractual agreements, including charging patients and Delta Dental appropriately and reporting claims accurately.
  • Conducting clinical patient examinations by independent dentist consultants, who provide unbiased opinions not only on whether services meet accepted professional standards, but also whether dental services have been provided as submitted for payment.
  • Educating our clients, enrollees, dentists and employees about fraud detection and prevention in online and printed newsletters and on our web site.
  • In some cases, pursuing recovery of funds in instances of suspected fraud.
  • Terminating the Delta Dental participation agreements of dentists who commit fraud.
  • Reporting potential cases to state and federal law enforcement personnel and cooperating with fraud investigations, including those conducted by state dental boards, postal inspectors and the FBI.

Protect Your Practice From Fraud

Learning about fraud is a great start. You can also:

  • Be sure to make reasonable efforts to collect patient coinsurance/copayments. Reasonable efforts include:
    • Payment plans: Making arrangements with patients for monthly payments, for example, or offering the option to pay by credit card.
    • Billing statements: Mailing monthly reminders of the balance and the minimum amount due.
    • Collections: Forwarding large, uncollectable balances to a professional collection agency.
    • Discontinuing the relationship with a patient who will not make reasonable efforts to pay his or her portion.
  • Discuss coverage and fees with patients before treatment, especially for optional or non-covered services, so that they fully understand their financial obligations.
  • Write out a fraud policy, including what you consider to be fraud. Have everyone in the office read and sign the document.
  • Separate tasks related to payments. For example, assign one person to accept payments and another to make adjustments in patient records.
  • Review collection and production reports monthly. Reconcile collections to make sure your bank and office records agree.
  • Check the percentages on your monthly profit and loss records, as well as any changes. For example, if dental supplies cost about 8 percent of your income last year, and you’re spending 10 percent this year, it is important to investigate the increase in spending.
  • Use your practice management system. It may have built-in reports or features that can help you protect your practice from fraud. Ask your vendor about what's available.

1National Health Care Anti-Fraud Association, 2008