FYI

Dentist blog from Delta Dental

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Why your claims with x-rays are being denied and what you can do

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

Crowns

Pre-operative and periapical (depicting the apex) radiographic images are required when submitting crown procedures D2710 through D2794. Do not substitute a panoramic radiograph to replace periapical images. Radiographs must show the endodontic and periodontal state of the tooth and must be taken within one year of the crown prep procedure.

Photographs must accompany radiographs when evidence of necessity is not obvious on the radiographs.

Lab slips should be maintained as part of the patient record.

In this example, the following radiographic images fail to depict the entire tooth. Pre-operative radiographic images must show the apex (tip of the tooth’s root) and are requested to rule out associated periapical pathology.

In comparison, the following radiographic image correctly depicts the apices of the submitted teeth.

Common reasons for crown denials

Core buildup, including any pins

Periapical radiographs taken within one year of the planned treatment are required when submitting core buildup and post and core procedures D2950 through D2957.

Do not substitute a panoramic radiograph to replace periapical images.

A narrative is also required. Per the American Dental Association, build-ups should not be reported when the procedure only involves a filler to eliminate any undercut, box form, or concave irregularity in the preparation.

Common reasons for core buildup denials

  • 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.
  • 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.
  • 564. Submit clinical treatment narrative.
  • 5BU. The fee for buildups is included in the fee for the completed restoration unless there is extensive loss of tooth structure.

Endodontics

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.

The following radiographic image fails to depict completed root canal therapy on the submitted teeth.

In contrast, the following radiographic images correctly depict an acceptable pre-operative periapical x-ray and post-operative x-ray of completed root canal therapy on the submitted tooth.

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

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.

Periodontics, including scaling and root planning

When submitting periodontic procedures D4210 through D4212, D4240 through D4245, D4260 through D4285, D4341 through D4342 or D4381, you must include bitewing radiographs taken within 12 months of the planned treatment that show both arches of bone levels. Furthermore, loss of alveolar crest height beyond the normal 1-1.5-millimeter distance to the cementoenamel junction (CEJ) must be evident on radiographs. Periapical or panoramic radiographs can only be substituted when bone loss exceeds levels that can be captured in a vertical bitewing.

Other requirements include periodontal charting (probing) completed within the past 12 months, periodontal case type and diagnosis with detailed clinical chart notes regarding the necessity of the periodontal treatment.

The following bitewing x-ray is nondiagnostic, as the interproximal contacts are overlapped and fail to show bone loss. 

Compare this to the following bitewing x-ray, which depicts both appreciable bone loss and calculus. 

Common reasons for periodontic denials

  •  Benefits could not be determined because of missing full-mouth radiographic images. (Note: This code may also be used to request bitewing x-rays.)
  • 5F5. Submit dated pre-operative diagnostic radiographs, current periodontal chart, dated appointment schedule and clinical treatment notes. 
  • 426. Benefits could not be determined because of missing radiographic images, periodontal charting and treatment record.
  • 5GB/5GC. Submit current periodontal chart, dated pre-operative diagnostic radiographs and a copy of the patient treatment record.
  • 574. Benefits could not be determined because of missing periodontal charting.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 5GJ. Submit dated copy of the original treatment notes.
  • 5F8. Submitted documentation fails to support payment of benefits for scaling and root planing.

Crown lengthening

Pre-treatment bitewing radiographs taken within 12 months of the planned treatment are required when submitting for the crown lengthening procedure (D4249).

A detailed clinical narrative is also required.

When procedure D4249 is performed on the same day as the preparation/placement of the crown, a separate fee for procedure D4249 may not be charged to the patient or Delta Dental. Prior to final restoration of a tooth, a minimum of four weeks must be allowed following clinical crown lengthening.

Common reasons for crown lengthening denials

  • 573. Benefits could not be determined because of missing full-mouth radiographic images.   (Note: This code may also be used to request bitewing x-rays.)
  • 564. Submit clinical treatment narrative.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 9WA. The fee for this procedure is considered to be part of and included in the fee for a completed service.

Implant supported prosthetics

You are required to include current periapical radiographs, including the apex of the implant body and surrounding bone, when submitting for implant-supported prosthetic procedures D6055 through D6077, D6082 through D6088, D6094, D6097 through D6099, D6110 through D6123 and D6194 through D6195. 

Do not substitute a panoramic radiograph to replace periapical images. Pre-operative x-rays depicting each implant site are required to determine payment of benefits on pre-authorizations. We must receive post-operative x-rays of implant placement to determine payment of benefits on paid claims. These x-rays must depict the entire implant.

Photographs, if available, may also be submitted for review.

For example, the following panoramic radiographic x-ray is nondiagnostic. It fails to clearly depict implant placement at site #9. Do not substitute a panoramic radiograph to replace periapical images.

The following post-operative periapical x-ray, however, correctly depicts the apex of the implant body and surrounding bone.

Common reasons for implant-supported prosthetic denials

  • 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.
  • 586. Benefits could not be determined because of missing post-operative radiographic images.
  • 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.

Fixed prosthodontics (bridge abutment crowns)

When submitting for fixed prosthodontic procedures D6710 through D6794, you are required to include pre-operative periapical radiographs that show the current endodontic and periodontal state of the tooth. These x-rays must be taken within one year of the crown prep procedures. Do not substitute a panoramic radiograph to replace periapical images.

Photographs, if available, may also be submitted.

Lab slips should be maintained as part of the patient record.

In this example, the radiographic image is nondiagnostic, as it fails to clearly depict the submitted abutment teeth.

In comparison, the following radiographic images for proposed bridge 13-15 clearly depict abutment teeth #13 and #15.

Common reasons for fixed prosthodontic denials

  • 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.
  • 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.

Oral surgery (impacted tooth)

Current periapical or panoramic radiographs are required when submitting oral surgery procedures D7210 through D7241 and D7251. Radiographs are necessary to evaluate conditions detected by history and clinical examination and are essential to detect, diagnose, and treat conditions that otherwise may be difficult to identify.

Further, as the classification of impactions is based on the anatomical position of the tooth rather than the surgical technique employed in removal, preoperative radiographs should be maintained in the patient treatment record.

Detailed, tooth specific clinical chart notes regarding the necessity of the treatment and photographs, if available, should be submitted.

The following panoramic x-ray clearly depicts the anatomical position of the third molars.

Common reasons for oral surgery denials

  • 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.
  • 5T2. Benefits could not be determined because of missing pre-operative panoramic radiographic image.
  • 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.

General tips for submitting x-rays

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.

You can refer tothe Submission Requirements table, which is located on pages 4-1 through 4-3 of the 2022 Claims Processing Policies and Procedures Handbook, to identify the necessary documentation and clinical information required for review of specific procedure codes.Please refer to the specific procedure code in the handbook for more details regarding the description of procedures.

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.

During clinical review of claims and pre-treatment estimates, Delta Dental reserves the right to request radiographic images and documentation for procedures that otherwise may be identified as not requiring the submission of documentation.

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

Go green with paperless EOBs

If you’re enrolled in direct deposit payments, you’ll now receive electronic explanations of benefits (EOBs) instead of paper. This change is part of our effort to reduce our environmental footprint.

How will this affect me?

If you currently receive payments via direct deposit (also known as electronic funds transfers, or EFT), you’ll no longer receive paper EOBs in the mail. If you plan to sign up for direct deposit, you’ll automatically be switched to paperless EOBs once you do.

To view your paperless EOBs, just log in to your Provider Tools account. You can view, print and download all available documents.

Is there any action I need to take at this time?

No action is required at this time. This change went into effect on January 21.

Why should I sign up for direct deposit?

Enrolling in direct deposit is the fastest, easiest and safest way to receive payments. With direct deposit:

  • Your money is deposited directly to the bank account of your choice.
  • Funds are available sooner than with paper checks.
  • There’s no risk of postal delays or missing checks.

How do I sign up for direct deposit payments?

Just log in to your online account to sign up for direct deposits. If you don’t already have an account, you can register quickly and easily.

Claim tips: Dental implants

Implants and the procedures associated with them are not covered benefits under most Delta Dental plans. But when implant services are covered, most denials are because of coding errors rather than a lack of coverage.

Let’s take a look at some common reasons for denials for implants and the procedures and prostheses associated with them.

Prefabricated abutment vs. custom fabricated abutment

Prefabricated abutments and custom fabricated abutments use separate codes:

  • D6056: Prefabricated abutment — includes modification and placement
  • D6057: Custom fabricated abutment — includes placement

Prefabricated abutments are machine made and may require modification, while custom fabricated abutments are created by a laboratory process and are specific for an individual application.

Abutment-supported vs. implant-supported crowns

Abutment-supported crowns use a prefabricated abutment (D6056) or a custom fabricated abutment (D6057) to attach a prosthetic crown to the implant body. Abutment-supported single and fixed partial denture crowns require the submission of accompanying abutment codes.

Implant-supported crowns attach directly to the implant body without an abutment. Implant-supported single and fixed partial denture crowns do not require the submission of accompany abutment codes.

The following image contains an example of incorrect coding. In it, the dental office submitted custom fabricated abutments (which are coded D6057) with implant-supported crowns (coded D6065) for teeth #19 and 20. But implant-supported crowns are not attached to the implant with an abutment, so the procedures should have been coded as abutment-supported crowns.

In the following correctly coded image, the dental office submitted custom fabricated abutments (D6057) with abutment-supported crowns (D6058) for teeth #19 and 20 implant supported crowns, which are attached to the implant using an abutment.

If you receive a denial for abutment-supported or implant-supported crowns, it may be one of the following:

  • 161. Benefits could not be determined because of missing/conflicting information
  • 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Single implant crowns vs. fixed partial denture implant crowns

A prosthetic crown that is used to restore one implant is known as a single implant crown. A prosthetic crown that is attached to an implant and is used as a bridge anchor to replace missing teeth is known as a fixed partial denture implant crown.

Here is an example of incorrect coding for these crowns.

ToothCode
#29D6065 (incorrect)
#30D6245
#31D6065 (incorrect)

In this example, the coding is incorrect because the abutments on teeth #29 and 31 are coded as single crowns. For this restoration, the following coding is correct:

ToothCode
#29D6075 (correct)
#30D6245
#31D6075 (correct)

Here, the abutments on teeth #29 and 31 are correctly coded as fixed partial denture crowns.

Natural tooth single crown and fixed partial denture retainer crown codes are often used in error to code implant-supported prosthetics. Instead, they should be coded as fixed partial denture implant crowns.

Incorrect, coded as natural teethCorrect, coded as implants
D6740, #29 (incorrect)
D6056, #29
D6245, #30
D6740, #31 (incorrect)
D6056, #31
D6068, #29 (correct)
D6056, #29
D6245, #30
D6068, #31 (correct)
D6056, #31

If you receive a denial for single implant or fixed partial denture implant crowns, it may be one of the following:

  • 161. Benefits could not be determined because of missing/conflicting information
  • 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Alternate benefits when there is no implant coverage

Delta Dental’s standard plans pay an allowance or alternate benefit towards the cost of implant-supported prosthodontic appliances, subject to the same limitations as standard prosthodontic services. The allowance is based on the fee for a standard pontic procedure. The patient is responsible for any difference in the cost of the implant-supported procedure.

Denial codes for alternate benefits when there’s no implant coverage may be one of the following:

  • FLM. An alternate procedure/benefit has been applied.
  • 503. This service isn’t a covered benefit of the enrollee’s program. An alternate procedure/benefit has been applied.

Implant with natural tooth bridge

When dental implants are covered by a patient’s plan, the fees for the placement of an implant to support a hybrid natural tooth and implant-supported bridge will be denied. Under our guidelines, a fixed partial denture should be retained by either all natural teeth or all implants, not a combination of the two. In the absence of a stress breaker, implant/natural tooth hybrid bridges will be denied. Bridges anchored this way severely stress the natural tooth and the implant and eventually cause bone loss, mobility and bridge failure.

Denial codes for hybrid bridges may include the following:

  • 5A1. The long-term prospects of a tooth must be considered. Under our guidelines, a fixed partial denture should be retained by either all natural teeth or all implants, not a combination of the two.

Congenitally missing teeth

Implant placement will not be considered for the replacement of congenitally missing permanent teeth or for the correction of other developmental or congenital defects resulting in spacing due to migration or drifting of teeth.

Denial codes for congenitally missing teeth implant placement may include the following:

  • 511. Procedures to correct congenital or developmental malformations are not covered.

Associated denials related to implant procedures

X-rays

Pre-operative x-rays depicting each implant site are required to determine the payment of benefits on pre-authorizations. Post-operative x-rays of implant placement are required to determine payment of benefits on paid claims and must depict the entire implant. Implant length, width and location must be appropriate for the clinical condition and allow for adequate function of the implant-supported restoration/prosthesis.

Denial codes for x-rays may include the following:

  • 570. Benefits could not be determined because of missing pre-operative radiographic images.
  • 586. Benefits could not be determined because of missing post-operative radiographic images.
  • 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.

Re-cementation of implant prosthetics

The code D2920 (re-cement or re-bond natural tooth crown) is often used in error to code re-cementation of implant prosthetics. The appropriate implant crown recement codes are as follows:

  • D6092 – Re-cement or re-bond implant/abutment supported crown
  • D6093 – Re-cement or re-bond implant/abutment supported fixed partial denture

Denial codes for re-cementation may include the following:

  • 788. A benefit allowance cannot be made for the requested procedure as our records show that this tooth was previously extracted.
  • 161. Benefits could not be determined because of missing/conflicting information.

Edentulous arches

For a completely edentulous arch, replacement of teeth and restoration of the occlusion can be adequately restored with four to six dental implants.

D6190 – Radiographic/surgical implant index, by report

When your patients’ plans include implant benefits, Delta Dental considers the fee for procedure D6190 to be included in the fee for the definitive treatment for one implant. A separate fee may not be charged to the patient or Delta Dental. Under contracts with implant coverage, procedure D6190 may be covered at the prosthetic benefit level when two or more implants are placed during the same treatment episode. If implants are not covered by the patient’s plan, this procedure is not a benefit, and the patient is responsible for the fee.

Denial codes related to D6190 may include the following:

  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
  • 7BB. This service is not a covered benefit of the enrollee’s plan.

D6011 – Second stage implant surgery

When implant services are covered by the patient’s contract, Delta Dental considers the fee for this procedure to be included in the fee for procedure D6010, surgical placement of implant body. A separate fee may not be charged to the patient or Delta Dental.

Denial codes related to D6011 may include the following:

  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
  • 718. This fee for this procedure is considered to be part of, and included in the fee for, a completed service.

D6199 – Unspecified implant procedure, by report

Please provide a narrative report with a complete description of the procedure and its rationale. Tools used, parts, healing caps, etc. will be considered inclusive in the implant procedure and not a separate benefit.

Denial codes related to D6199 may include the following:

  • 564. Submit clinical treatment narrative.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.

Delta Dental’s processing policies for implants and the procedures and prostheses associated with them should be considered guidelines. Whenever an exceptional case is involved, please provide a full narrative description and any available supporting documentation to help our staff determine benefits. To ensure timely benefit determination, always submit the appropriate supporting documentation on your initial submission.

Why your SRP claims are denied and what you can do

Claims for periodontal scaling and root planing (D4341 and D4342) are denied more frequently than those for many other procedures, according to the American Dental Association.

Delta Dental defines periodontal scaling and root planing (SRP) as “a definitive non-surgical periodontal treatment involving the judicious and thorough planing of the root surface.” The procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus.

Although you should always refer to the Delta Dental Dentist Handbook for specific processing policies and guidelines, we’ll highlight some common reasons for denials for SRP and associated procedures.

Documentation fails to support payment of SRP

Delta Dental considers a quadrant of procedure D4341 to consist of at least four diseased teeth (4-6mm pockets, early bone loss).

  • When fewer than four diseased teeth are involved, Delta Dental bases its allowances on procedure D4342.
  • In addition to qualifying pocketing, radiographs must show loss of alveolar crest height beyond the normal 1-1.5mm distance to the cemento-enamel junction (CEJ).
  • Exposure of cemental surfaces of the roots is necessary for root planing.
  • Without a reduction in the alveolar crest level, root planing isn’t achievable.
Qualifying: X-rays clearly shows appreciable bone loss and calculus
Non-qualifying: X-rays show no appreciable bone loss and calculus 

Denial code: 5F8. Submitted documentation fails to support payment of benefits for scaling and root planing.

Submission of more than two quads of SRP on the same date of service

Without supporting documentation, the fees for more than two quadrants of SRP performed on the same date of service are disallowed. Acceptable supporting documentation includes:

  • Clinical progress notes
  • Evidence of length of appointment (successful scaling typically takes 30-45 minutes per quadrant with local anesthesia)
  • Information about the local anesthetic used
  • The reason for performing more than two quadrants on the same date of service

Four quadrants of SRP may be approved on a pre-authorization when criteria are met. However, you’re expected to know the policy upon payment.

Denial code: 447. No more than two quadrants of scaling and root planing are allowable on the same date of service.

Inadequate periodontal charting or x-rays

The D4341 and D4342 procedures require you to submit periodontal charting that indicates at least Case Type II periodontal disease (4-6mm pockets, early bone loss).

  • Periodontal charting should be dated no more than 12 months before the date of service.
  • Full-mouth series or bitewings that clearly show appreciable bone loss are preferred because these images are usually the most accurate determinant of bone loss.
  • Submit corresponding images for each submitted quadrant.
Qualifying: Labeled periodontal charting that indicates exam date
Non-qualifying: X-ray is non-diagnostic as interproximal contacts are overlapped and fail to show bone loss

Denial codes:

  • 5F8. Submitted documentation fails to support payment of benefits for scaling and root planing.
  • 574. Benefits could not be determined because of missing periodontal charting.
  • 570. Benefits could not be determined because of missing pre-operative radiographic images.
  • 573. Benefits could not be determined because of missing full mouth radiographic images.
  • 569. Benefits could not be determined because of the non-diagnostic nature of the radiographic images submitted.
  • 426. Benefits could not be determined because of missing radiographic images, periodontal charting, and treatment record.
  • 5GB/5GC. Submit current periodontal chart, dated pre-operative diagnostic radiographs, and a copy of the patient treatment record.

Associated denials related to SRP

Gingival irrigation (D4921)

Gingival irrigation isn’t a separately payable procedure when provided in conjunction with SRP or any other periodontal procedures. You can’t charge a separate fee for the procedure to Delta Dental or the patient.

Denial code: 449. The fee for gingival irrigation is included in the fee for any periodontal services performed on the same date of service.

Localized delivery of antimicrobial agents (D4381)

This procedure isn’t a benefit under some plans and requires you to submit periodontal charting indicating pockets of at least 5mm. When submitted with nonqualifying SRP, these procedures will be denied due to conflict with the denied SRP.

Denial codes:

  • 7BB. This service is not a covered benefit of the enrollee’s program.
  • 7C2. The submitted procedure is not payable due to the absence or conflict of a related service.

Unspecified periodontal procedure (D4999)

These are most commonly submitted as bacterial decontamination, laser or irrigation.

Delta Dental considers specialized techniques, such as those that use lasers or antibacterial medicaments, to be included in the fee for any SRP or surgical procedure. You can’t charge a separate fee for the procedure to Delta Dental or the patient.

Don’t forget:

  • Delta Dental pays for completed procedures, not tools used for treatment.
  • Please provide a narrative report with a complete description of the procedure and its rationale.

Denial codes:

  • 440. The fee for this procedure is considered part of and included in the fee for periodontal services.
  • 9WA. The fee for this procedure is considered to be part of, and included in the fee for, a completed service.
  • 564. Submit clinical treatment narrative.

Delta Dental’s periodontal processing policies described above should be considered guidelines. Whenever an exceptional case is involved, please provide a full narrative description and any available supporting documentation to help our staff determine benefits.

And remember, to ensure timely benefit determination, always submit the appropriate supporting documentation on your initial submission.

CDT 2022 updates have arrived

The American Dental Association’s CDT procedure codes and nomenclature* have been updated for 2022. Changes include 24 new codes, five code deletions and 22 nomenclature and description revisions.

Please review our summary of changes and claims processing policies (PDF) and begin using CDT 2022 codes on claims for procedures provided on and after Jan. 1, 2022.

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


Note: The PDF has been updated to allow printing.

Dental fraud — what it is and how you can help fight it

An estimated 3% of the United States’ total spending on health care is caused by fraud, according to the National Health Care Anti-Fraud Association. That may sound like a small percentage, but with dental spending projected to reach $203 billion by 2027, that means we can expect to face over $6 billion in dental fraud.

Dental 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 (ADA). Fraud can take many forms, but it requires intent, deception and unlawful gain.

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 professional licenses and even jail time!

Educate yourself and your staff on how to stay on the right side of the law. The ADA (PDF) and Delta Dental can help you, and your state’s dental board may have resources as well.

Common signs of fraud to watch out for

Because fraud requires intent and deception, there are signs that you and your staff can watch out for from patients who commit dental fraud. Stay alert for:

  • Patients who use another person’s ID or multiple IDs to obtain benefits
  • Patients who request that you misreport dates to circumvent calendar year maximums or limitations
  • Patients who misrepresent their available coverage or ask you to misrepresent care to their insurance (including concealing dual coverage)

Because fraud can be perpetrated by both patients and care providers, having clear policies can help prevent fraud before it begins. Make sure your practice prohibits the following:

  • Regular failure to collect a patient’s payment without notifying the carrier
  • Claims for covered services when non-covered services are provided
  • Recommendation of unnecessary services

Although fraud requires intent, it’s possible to commit mistakes that could unknowingly get you into trouble. It’s entirely possible to unknowingly commit fraud in an attempt to help patients who might be seeking help with their coverage. For example, waiving coinsurance costs is one example of this. In other cases, it might be a simple oversight. Common mistakes considered fraud include:

  • Listing the incorrect treating dentist on a claim
  • Coding the wrong treatment (for example, prophylaxis vs. periodontal maintenance)
  • Altering dates of service

What you can do to help protect your practice

Fraud can happen at any point in the process of providing care, accepting payment and submitting claims, but having clear, consistently applied policies for your practice can help everyone play their part in fighting fraud. Here are some general steps your practice can take.

  • Make arrangements for payment with patients prior to providing services. This includes discussing coverage and fees, especially for optional and non-covered services, so that patients fully understand what their financial obligations are.
  • Discontinue relationships with patients who don’t make reasonable efforts to pay.
  • Write out a fraud policy, including examples. Make sure that your office staff has read and signed this policy.
  • Divide the tasks related to processing payments among multiple staff members. For example, have one person accept payments and another make the adjustments in patient records.
  • As a dentist or practice owner, review the claims your practice submits. Claims are considered to be legal documents submitted with your authorization. The dentist listed is legally responsible for the accuracy and honesty of a claim, even if an office manager or other staff member submits the claim.

Here are some things you can do every month to help fight fraud.

  • Mail monthly reminders to patients of their balances and minimums due.
  • Forward large uncollectable balances to a professional collections agency.
  • Review collection and production reports each month. Make sure your bank statement and your office records agree.
  • Check the percentages on your monthly profit and loss records, as well as any year-over-year changes. For example, if supplies cost about 8% of your income a year ago and you’re spending 10% this year, find out why.

What Delta Dental does to help prevent fraud

You don’t have to combat fraud on your own. We’re proud to be your partners in working to eliminate fraud at all levels and steps of the dental care process. What we do includes:

  • Educate our clients, members, dentists and employees about fraud detection and prevention
  • Conduct clinical patient examinations to ensure that provided services meet professional standards and were correctly submitted
  • Review financial and treatment records to ensure contracts are followed
  • Report potential cases to state and federal law enforcement and cooperate with fraud investigations
  • Pursue the recovery of funds when fraud is suspected
  • Terminate contracts when fraud is confirmed

If you suspect someone is committing fraud, report it. Call Delta Dental’s Anti-Fraud Hotline at 800-526-1852. You may remain anonymous during this call.

By making sure that you and your staff stay on top of the law, having understandable and consistent policies and maintaining good relationships with paying patients, you can help keep your practice in the green and trouble-free.

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