Areas of Practice Plan Analyzer Contact

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Our mission is to promote value and appropriateness of care.

Fraud or Abuse: A Matter of Intent

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.

Common abuses:

  • Upcoding: Billing for a more difficult procedure than is actually performed.
  • Unbundling: Billing components of a procedure separately to increase compensation.

Unquestionably fraud:

  • 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

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