Insurance Fraud Defined

Insurance Fraud

So I want to address something that keeps coming up as misinformation in the dental circles. Fraud is basically defined as misrepresenting information for financial gain. Common examples are:

1) Billing for something you did not do

2) Billing for something more than you did

What often is misunderstood is that billing cash patients at a different rate is also fraud, and is also against ADA code of conduct for all dentists.

As an example: 

“Mrs. Jones, you need a crown. The normal price is $1500, but since you are paying in cash it will be $1000.”

This is Fraud, the most basic definition of it. It is not about Mrs. Jones, but about ALL other insurance patients if you put $1500 on your claim forms. In this example your normal fee is $1000 and that is what MUST be represented on claims forms. Your normal fee is what you would charge a cash patient. You MUST treat all patients the same regardless if there is 3rd party involvement or not.

Now, what is also misunderstood is what is NOT fraud.

Billing for something you did, on the day you did it….this is NEVER fraud.

Now, that might seem like a silly statement, but here is the common misconception out there.

“Insurance company A pays the crown code on seat date, therefore it is fraud to submit it on prep date.”

INCORRECT!

Insurance is only dictating when they will PAY the claim.

Again, like the above cash patient, you need to treat ALL patients the same. That includes how many x-rays you take, what procedures you do, how much you charge, and when you bill procedures.

It is common, normal, acceptable and IMO better to charge ALL crowns on the day you prep them. For the insurance companies that pay on seat date, great, put a narrative in on what day that is scheduled. You have now satisfied the information they want to see. The crown is likely to be cemented before they even process the claim anyway.

Hopefully this gives you a better understanding of what FRAUD is, and what it is not. Protect yourself, but don’t go overboard.