Fraud involves intentionally deceiving or misrepresenting the extent, difficulty or delivery of services to obtain an unauthorized benefit. In a field that is as much art as science, there are many ways to describe treatments. Abuse is sometimes used to indicate aggressive billing practices, when intent cannot be proven.
- Upcoding: Billing for a more difficult procedure than is actually performed.
- Unbundling: Billing components of a procedure separately to increase compensation.
- Misrepresentation: Coding non covered services as covered ones.
- Unnecessary services: Treatments of little or no therapeutic value
- Waiver of co-payments and deductibles: Some dentists will forgive their patients out of pocket expenses and recoup the loss with additional services.
- Billing services not provided: These are sometimes included with legitimate charges.
Fight back with:
- Best practices plan language
- Professional review
- Fraud prevention policy
- Periodic reevaluation and updating of procedures
- Profiling of providers