Dentist blog from Delta Dental

5 common billing practices that may be fraud

Have you ever waived a copayment after a patient asked you to or unbundled procedure codes because you couldn’t find the one you were looking for? Depending on the circumstances, you could be considered negligent or even convicted of fraud.

What is fraud?

Dental insurance fraud is “any crime where an individual receives insurance money for filing a false claim, inflating a claim or billing for services not rendered,” according to the American Dental Association.

Fraud can take many forms, but it requires intent, deception and unlawful gain. It is possible to unintentionally take action that could get you into trouble — but what differentiates fraud from negligence is intent. For example, purposefully misrepresenting information in a claim so that you, your practice or your patients receive more money is considered fraud.

Common fraudulent billing practices

There are many billing and claims habits that are fraudulent. The most common types of billing fraud are:

  • Billing for services not performed or not completed. When submitting claims, it’s important to ensure that all services included in the claim were performed or completed. Avoid inflating claims, like upgrading a simple extraction to a more complex surgical extraction or reporting a routine cleaning as a periodontal deep cleaning, which is more expensive.
  • Waiving deductibles or copayments. Some Delta Dental plans include deductible or maximum waivers for diagnostic and preventive services (D&P), but not all do. Similarly, although most Delta Dental plans cover D&P in network at 100%, some plans may have a lower benefit level, such as 80% or 90%, and require a patient coinsurance. Waiving these payments when required is considered fraud because the fee you billed on the claim is not the total fee you intend to collect. If patients insist that you waive these payments, you could consider offering a payment plan or denying care.
  • Altering dates of service. This occurs when a claim is submitted with an incorrect date of service. A common example of this is submitting a claim for a crown on the preparation date rather than the seat/cementation date. While this may seem initially harmless, the date of service could affect coverage for patients if the treatment occurred before their plan’s effective date or before the end of their plan’s waiting period.
  • Submitting a claim for treatment using a different member’s information. Always confirm that you’re submitting claims for the correct patient. The date on which a procedure is performed is connected to the patient’s medical eligibility and waiting periods. Treating one patient and intentionally submitting the claim under another patient’s name in order to have the procedure covered is fraudulent.
  • Improper use of additional codes. When submitting the codes for treatments, always use the most apt code. If there’s a code for a single service like an extraction, don’t separate out each part of the procedure into codes for individual actions like local anesthesia, incisions, drainage and sutures. This is called unbundling and is not permitted.

How to report fraud

If you suspect fraud has been committed, you can call the Delta Dental Anti-Fraud Hotline at 800-526-1852 or submit our online form for reporting potential fraudulent activity. You may choose to stay anonymous when you report fraud.

After receiving reports of suspicious activity, Delta Dental will investigate. We use tips, reports and utilization analysis to look for unusual patterns that may indicate fraud and we may work with law enforcement if needed.

Why fraud prevention matters

Fraud harms everyone in the dental industry. It not only drives up the cost of coverage for patients and employers, but it can also directly affect your practice. Being found guilty of perpetrating fraud can result in fines, loss of network participation and professional licenses and even jail time.

For more information about fraud, visit Delta Dental’s fraud and abuse resources.

How to submit appropriate x-rays for endodontic claims

Some endodontic procedure codes require the submission of documentation with Delta Dental PPO™ and Delta Dental Premier® claims. Let’s review radiographic image requirements for these procedures and the associated denials that can occur.

When are radiographs required?

Pre-operative and post-operative periapical radiographs are required when submitting endodontic procedures D3310 through D3330 and D3921. All radiographs, including working radiographs, should be maintained in the patient treatment record. Pre-operative periapical radiographs must be submitted with pre-treatment estimates, and both pre-operative and post-operative periapical radiographs must be submitted with claims upon completion of procedures.

What do correct radiographs look like?

The following radiographic images correctly depict an acceptable pre-operative and post-operative periapical x-ray of completed root canal therapy on tooth #18.

In this second example below, the radiographic images correctly depict an acceptable pre-operative and post-operative periapical x-ray of completed root canal therapy on tooth #19.

In this third example, the radiographic images correctly depict an acceptable pre-operative and post-operative periapical x-ray of completed root canal therapy on tooth #11.

What do unsuitable radiographs look like?

The following radiographic image fails to depict completed root canal therapy on tooth #18. Submitted post-operative periapical radiographs must depict the completed root canal.

Working radiographs (x-rays used to confirm the root length) and gutta percha fit radiographs (x-rays used to confirm the root canal material extends to the appropriate length) may be submitted as pre-operative periapical x-rays.

However, they are unacceptable when submitted as post-operative periapical x-rays, as they fail to depict the completed root canal.

The following radiographic image fails to depict the entire, completed root canal therapy on tooth #31. The final endodontic x-ray must depict the apex. 

Bitewing and other radiographs that do not depict the apex of the tooth are inadequate, as the placement, density and depth of the root canal filling material cannot be fully evaluated.

What codes accompany endodontic claim denials?

If your endodontic claim is denied, you may see one of the following denial codes:

  • 570. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • 5L8. Benefits could not be determined because of missing pre-operative periapical radiographic images.
  • FMW. Benefits could not be determined because of missing pre- and post-operative periapical images.
  • 8L9. Benefits could not be determined because of missing post-operative radiographic images of completed root canal therapy.
  • 5RX. Benefits could not be determined, because the submitted radiograph does not depict the entire tooth.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.

To expedite the processing of your claim and to ensure timely benefit determination, always submit the appropriate mounted and dated x-rays and supporting documentation on your initial submission. Enter the required documentation information in the Remarks or Comments field of the claim.

Please do not submit original radiographic images if they are the only diagnostic record for your patient. Duplicate radiographs or radiographic image copies of diagnostic quality, including paper copies of digitized images, are acceptable. We do not return radiographic images or other documentation submitted with paper claims; however, we will make an exception when we receive a stamped, self-addressed envelope with the claim.

CDT coding and nomenclature are the copyright and a trademark of the American Dental Association, all rights reserved.

Dentist spotlight: Dr. Lyudmila Kravchuk

Driven to become a dentist since she was in high school, Lyudmila Kravchuk, DDS, hasn’t let any obstacles stop her from achieving her goal. Originally from Ukraine, Dr. Kravchuk trained in Latvia and now runs a practice in Citrus Heights, California.

Her passion for transforming patients’ lives through dental health motivates her work as a dentist and keeps her patients returning to her practice year after year.

Our Dental Health Partner of the Month for August, Dr. Kravchuk has also been recognized for her dental work in the local community by Russian Time Magazine and the Slavic Community Center of Sacramento.

We caught up with Dr. Kravchuk after a busy week to discuss her story and why she still loves dentistry after four decades.

Tell us a little bit about yourself.

My name is Dr. Lyudmila Kravchuk, I own a dental practice in Citrus Heights, California, and I do general dentistry. I work with patients of all ages. I opened my solo practice 17 years ago.

I was born in Ukraine. I decided to become a dentist after I graduated high school. I was living in Ukraine at the time. As a Christian, I didn’t join the Communist Party because it was against my values. But because I wasn’t a Communist Party member, no dental school in Ukraine would admit me, so I attended dental school in Latvia. Latvia was also a country in the former USSR, but they had slightly more religious freedom, so I was able to move there to go to dental school.

After finishing the dental program, I moved back to Ukraine, where I started working as a dentist. I worked in Ukraine for 15 years.

Why did you decide to become a dentist?

When I was in school, I knew I wanted to be in medical field the whole time. I thought I’d like family medicine, but it was extremely difficult to get into school for that. So, I decided to go into dentistry, and I really liked it! I’ve been working in dentistry for 41 years now.

When did you move to the United States?

I moved in the United States in 1994 with my husband, two children and my in-laws. I learned that California had a program for foreign dentists, and after passing the board exam in 1995, I got a California license.

When I arrived, I didn’t speak a word of English ― I’d never even heard English before. To teach myself, I started with a dictionary. I would read, and then I would write on the other side of the paper what the word meant. Those were my English classes, basically: dictionary, paper and a pen.

How did you settle on Citrus Heights? What made you decide to move there?

The Sacramento area has a large Slavic community, and I already knew a lot of people here. For my first five years in the U.S., I worked for a dental group. They told me that I was the dentist the doing most production for their office, so I decided to start my own practice! I opened my dental office here in 2005.

Tell us about your day-to-day. What kind of patients do you see? What do you do?

I see all different kinds of patients. My assistant takes x-rays, but I do the exam and treatment plan. I do everything from start to finish except for implants.

These days, I try not to work on Fridays, but I work on demand. If people tell me that they can only come in on a Friday, then I’m happy to come in. Sometimes people even come from San Francisco and Seattle. I have a couple of patients from Boise, and I even have one who called an hour ago coming from Missouri.

Wow! Why do you think patients come from so far to see you?

I think it’s because they trust me. Some of them have known me for 40 years.

What do you enjoy most about being a dentist?

Well, I like to do root canals! I like challenges. I like when people leave happy and smiling. And sometimes when people get new teeth, it can even be life changing. They’re more self-confident when they have a nice smile ― they’re no longer depressed, and they make new friends. Making people happy, when they leave my office happy — that’s what I enjoy most.

As I mentioned, there’s a large and diverse Slavic community here, and many of them come to my practice because there’s no language barrier, especially in the case of the elderly population. Many people are often anxious about going to the dentist, so I try to make it a simple, relaxed experience for them — no pressure.

When you’re not practicing dentistry, what do you like to do in your free time?

I love gardening, I love traveling, and I have seven grandkids in the area who come by my house on the weekends. They keep me busy! Even though I love gardening, I’m doing it less and less every year. I’m busier with the grandkids and with traveling to new places with the family.

I understand that your son has a pretty interesting job.

Yes, he does. He graduated with a degree in master choral orchestra conducting. He’s a high school music teacher, but he also has a non-profit choir, Slavic Chorale. They perform at all kinds of different events and perform in different languages. He absolutely loves choir — he’s into it every day. By the way, I wanted him to be a dentist or doctor, but it wasn’t his thing.

My daughter has been a physician’s assistant for 12 years, though, so I did get one child involved in the medical industry!

What challenges do you see facing the dental industry in the future?

I think that the biggest challenges that I see are dentistry becoming more corporate and the increasing student loans for dental students.

As dentistry becomes more and more corporate, small private practices might get pushed out of the competition. As a result, it’s going to be more and more difficult to have a dentist who can truly be your family dentist over the years. It’s going to be more like a factory instead.

Also, student loans are getting larger and larger, which makes it so much more difficult for new graduates to open their own practice.

It sounds like there are a lot of challenges for recent graduates of dental school. What advice would you give them?

I’d advise them to go to work with another dentist as associate in an office and try to do different kinds of procedures.

Also, try to be nice to people. Be patient. Make them smile.

Congratulations to Dr. Lyudmila Kravchuk on being our Dental Health Partner of the Month! Thank you for sharing your story with us. To learn more about Dr. Kravchuk and her practice, check out Lyudmila Kravchuk Dental Corporation on Facebook.

Your dental policy brief: News updates as of August 2

From the latest on Medicare to recent court rulings affecting dentistry, FYI brings you the biggest dental policy stories.

CMS proposes Medicare dental coverage expansion after push from Congress

The U.S. Centers for Medicare and Medicaid Services (CMS) has released a proposed physician fee schedule rule for 2023 that would expand access to dental care services for Medicare beneficiaries. The proposal came after lawmakers in the U.S. House of Representatives and the U.S. Senate requested that the agency broaden the definition of medically necessary dental coverage as a way to expand access for Medicare recipients.

Currently, Medicare Part B only pays for dental services when it is deemed medically necessary to treat a recipient’s primary medical condition. The proposed changes for payments could become effective as early as January 1, 2023.

ADA says ransomware behind recent cyberattack, confirms data theft

The American Dental Association (ADA) has said that the cybersecurity incident it first reported in April was actually a ransomware attack, which ultimately led to the theft of member data. Although the ADA initially claimed that there was no data breach, a recent notice from the organization confirms that data theft occurred.

The notice does not share the precise data impacted, just that it was personal information tied to member names. Impacted members will receive complimentary credit monitoring and identity protection services. The ADA says it has assessed system security and reset relevant account passwords while it works to review and bolster existing policies and procedures.

Federal judge rejects Colorado inmate’s request for change in prison dental policy

A federal judge has denied an inmate’s request to order prison officials to halt their alleged unofficial policy of denying dental crowns to detainees. Beginning in November 2019, an inmate at the U.S. Penitentiary Administrative Maximum Facility in Florence, Colorado, sought treatment for broken and painful teeth. The prison dentist allegedly informed the inmate he needed a crown and teeth fillings, but the dentist could only “do one procedure per inmate per visit.”

The inmate, Peter George Noe, filed suit against the government and multiple medical personnel, claiming delayed and inadequate treatment. He asked for a preliminary injunction that would order the Bureau of Prisons to provide crowns generally, and to specifically perform his needed dental work. The district judge denied the motion, finding Noe had not shown he would suffer irreparable harm in the absence of a court order.

Supreme Court rejects dental hygienist’s medical marijuana workers’ comp case

The U.S. Supreme Court declined to hear the case of a Minnesota dental hygienist challenging denial of workers’ compensation for medical marijuana. The hygienist, Susan K. Musta, began purchasing cannabis to treat chronic pain due to work-related injuries in 2019 under Minnesota’s legal medical cannabis program and was not reimbursed for it under her workers’ compensation coverage for workplace injuries. Minnesota courts ruled that the federal Controlled Substances Act (CSA) prevented her insurer from paying for medical cannabis.

Musta appealed the decision to the U.S. Supreme Court alongside a similar Minnesota case. The U.S. Supreme Court indicated that fewer than four justices believed the legal challenge warranted the court’s consideration. State supreme courts in New Jersey and New Hampshire have ruled the CSA doesn’t preempt their workers’ compensation laws. However, like Minnesota, Maine’s high court reached the opposite conclusion.

New conference schedule announced

After two years of absence due to the COVID-19 pandemic, Delta Dental representatives are back out on the conference circuit. We’ll be at several notable events this fall.

Look for us at the following conferences:

American Association of Dental Office Management (AADOM)September 8–10, 2022Scottsdale, AZ (Booth #628)
American Dental Association – SmileConOctober 13–15, 2022Houston, TX (Booth #904)
Greater NY Dental MeetingNovember 27–30, 2022New York, NY (Booth #2308)

Stop by our booth at the ADA’s SmileCon to talk to Dr. Jessica Buehler, our director of dental affairs.

We’d love to see you at one of these upcoming events! Please visit our booth to meet local provider network ambassadors, learn about Delta Dental’s online services, hear the latest news and trends, get your questions answered and pick up cool swag.

Upcoming webinars for August: Provider Tools and Community Care Network

Is your practice feeling a mid-year slump? Sign up for these free webinars to reinvigorate your practice. You’ll learn how to maximize productivity with Provider Tools and expand your business’s reach with the Veterans Affairs Community Care Network (VA CCN).

Provider Tools webinars

Delta Dental’s Provider Tools webinars give you the tools to boost your office’s productivity by submitting claims online, enrolling in direct deposit, looking up patients’ coverage information and more. There’s also a special DeltaCare® USA-focused webinar scheduled for later in the month.

Sign up for this month’s Provider Tools webinars:

If you have a specific question about Provider Tools, you can also schedule a 1:1 video call. If there are any topics you’d like to us to address, share your thoughts with us at

Community Care Network webinars

Our VA Community Care Network introductory webinars provide an overview of the valuable resources and helpful information that will let you expand your patient base by serving America’s Veterans. You’ll learn how Delta Dental can partner with you to navigate the VA CCN.

Join this month’s webinars:

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