Updated on February 7, 2024
6 min read

5 Illegal Dental Billing Practices and How to Avoid Them

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It’s important to understand a few things about dental billing as a dental patient. Fraudulent billing practices can cost you money and jeopardize your dentist’s practice. Knowing what to look for will help you avoid being taken advantage of.

In this article, we’ll discuss how dental bills work, ways they could potentially be fraudulent, and how to protect yourself from dental billing fraud.

What Are Illegal Dental Billing Practices?

When dentists bill for services, they’re expected to be honest about what services were performed and what they charged. But dentists can make fraudulent claims, especially when insurance companies or federal healthcare programs enter the picture.

If you have dental insurance, it may cover all or part of a given treatment. Your dentist can get more money from your insurance provider by claiming the completion of additional services or inflating costs.

These fraudulent claims are illegal and can cost you and your insurance company. If insurance will not fully cover the cost of a certain treatment, your dentist may pass on the rest of that extra cost to you.

What Are the Signs of Fraudulent Billing?

It’s not always easy to spot fraudulent dental billing, but there are some possible tells, including:

  • A discrepancy between the cost you’re initially quoted and the price you end up paying after treatment
  • Items on a bill that don’t seem to reflect your treatment
  • Inaccurate treatment dates or personal information

Keep in mind that fraud requires intent. It’s possible for dental office staff to unknowingly file bills illegally due to human error.

For example, your records could be confused with someone else’s. Alternatively, the dental office may neglect to update information when you switch to a new insurance provider or when they get new dental billing software. This would be considered negligence rather than fraud.

However, dental billing mistakes like these can cost you money and put your dental office in legal trouble. Intentional or not, you should question any discrepancies in your bill.

Common Types of Dental Billing Fraud

Common illegal dental billing practices include:

  • Upcoding Each dental procedure has a designated code insurance providers use to verify the cost. By “upcoding” or listing a treatment with a more expensive code, a dental office can receive more money than they’re entitled to.
  • Unbundling Refers to listing one comprehensive procedure as several lesser procedures, increasing the claimed cost. A similar fraudulent billing practice is double billing, or submitting claims for the same procedure more than once.
  • Phantom charges A dental bill may list one or more services that didn’t take place.
  • Waiving copays Waiving copays or deductibles may sound nice to you as a patient, but it’s illegal. It gives your dentist an unfair advantage over competitors and may incentivize you to get treatment you don’t need.

The Consequences of Illegal Dental Billing

Dental insurance fraud can have monetary and legal repercussions, putting patients, dentists, and dental practice staff at risk.

What Risks Do Patients Face With Fraudulent Billing?

With fraudulent dental practices, losing money is the most obvious and immediate risk for you as a patient. If your dental office inflates their bills and your insurance coverage isn’t 100%, the remainder of the cost will likely be passed on to you.

This is especially risky if you pay out of pocket upfront and expect to be reimbursed afterward by your insurance. A fraudulent dental office might submit an additional claim without telling you.

Another risk to the patient is having to undergo unnecessary procedures. A dentist may recommend expensive and invasive treatments in cases that require no more than minor preventive care.

This means that, besides spending more money, you could needlessly undergo invasive treatment. You may also require follow-up procedures later, adding to the cost.

What Are the Legal Repercussions for Dentists?

Legal consequences for dentists or staff found guilty of fraud can vary. In most cases, the dentists will at least have to pay penalties or fines. Additional consequences can include suspension of their license, probation, and even prison time.

In some cases, dental office staff are found to have committed fraud without the knowledge of the practicing dentist. If this happens, the dentist might be found not guilty or guilty of negligence.

Protecting Yourself from Dental Billing Fraud

Being proactive and aware can help protect you from fraud. This includes paying attention to what you’re quoted and contacting your insurance provider.

How Can You Verify Your Dental Bills?

To verify your dental bills, you should look closely at two documents: one from your dentist and one from your insurance company.

The one from your dentist is a written statement detailing your treatment and estimated costs. Most dentists provide this upfront before treatment begins. If your dentist doesn’t give you a statement, it’s wise to ask for one.

On the insurance side, you should review your explanation of benefits (EOB). This is a document provided by your insurance carrier (online or by mail) once they’ve processed the claim.

By comparing your EOB and your dentist’s estimate, you can check to ensure everything looks accurate.

Steps to Take if You Suspect Billing Fraud

Do the following if you notice signs of potential fraud from your dental office:

  1. Contact your insurance company ⁠— Be prepared to be persistent, as not every staff member you speak with may want to pursue the issue. You want to make sure you get back whatever you’re owed.
  2. File a complaint with your state government ⁠— This is your next line of support. There should be a hotline or contact email for consumer complaints through your state’s Department of Insurance, Department of Financial Services, or Insurance Commissioner’s office.
  3. Contact other lines of support ⁠— You may consider contacting the National Healthcare Anti-Fraud Association (NHCAA) or the Healthcare Fraud Prevention Partnership (HFPP).

What Can Prevent Dental Billing Abuse?

To prevent dental billing mistakes or fraud, do the following:

  • Stay informed Getting a written statement and estimate from your dentist before treatment is a good first line of defense. Knowing what your insurance policy does and doesn’t cover will also help you identify potential inconsistencies.
  • Pay with a credit card If you want to be especially careful, consider paying with a credit card. Credit cards tend to have strict policies regarding fraud and may make things easier if you need to dispute a charge.
  • Get a second opinion If something about a dental practice doesn’t seem right, seeing a different dentist may give you some perspective.

Summary

Dental billing fraud can cost you money and time and result in the completion of unnecessary dental work. To protect yourself, be on the lookout for any unusual items or discrepancies in your dentist’s cost estimate. It also helps to know your insurance policy well.

Contacting your insurance carrier is a good first step if you suspect fraud. You can also contact your state’s insurance watchdog agency for more resources.

Last updated on February 7, 2024
7 Sources Cited
Last updated on February 7, 2024
All NewMouth content is medically reviewed and fact-checked by a licensed dentist or orthodontist to ensure the information is factual, current, and relevant.

We have strict sourcing guidelines and only cite from current scientific research, such as scholarly articles, dentistry textbooks, government agencies, and medical journals. This also includes information provided by the American Dental Association (ADA), the American Association of Orthodontics (AAO), and the American Academy of Pediatrics (AAP).
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  3. Fraud and Abuse.” American Dental Association.
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  6. Anderson et al. “A Comparative Expected Cost Analysis Study on Dental Services and Products Used in the United States.” Account and Financial Management Journal, 2019.
  7. Spivak, C. “Washington County dentist charged with fraud, accused of chipping teeth so he could crown them.” Milwaukee Journal Sentinel, 2020.
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