Medical coding and fraud

May 1, 2002
Most medical plans contain stipulations that eliminate coverage for any treatment involving "teeth." Com mon contract language states that no payment will be made to either a physician or a dentist for services in connection with the care, treatment, filling, removal, or replacement of teeth.

Most medical plans contain stipulations that eliminate coverage for any treatment involving "teeth." Com mon contract language states that no payment will be made to either a physician or a dentist for services in connection with the care, treatment, filling, removal, or replacement of teeth. The exception is if treatment is a result of acute accidental trauma to sound natural teeth or structures directly supporting the teeth. In addition, some medical plans will cover certain surgical procedures and/or TMJD issues and implants.

In the past, it has not been considered fraud to submit medical claims for dental treatment, as long as there was no effort to hide the fact that the practitioner was a dentist and dental and medical claims were not made simultaneously. Typically, the dental claim is sent first; then, if it is denied, a medical claim is submitted.

Now, some carriers have decided that any dentist using medical billing might be committing insurance fraud. Anecdotally, I have heard from several offices that have been singled out for submitting medical claims. In 1995, a Michigan dentist was successfully prosecuted for fraudulently billing several medical plans - including Blue Cross and Blue Shield - for services not performed. Currently, a full-page "ad" is being published in the pages of several dental magazines, including this one, by a dentist who also was successfully prosecuted for improper medical billing to Blue Cross, Blue Shield of Michigan. In large letters at the top of the ad, it states that he pled guilty to health-care fraud in 2001 for billing for gingi vectomy/gingivoplasty treatments under medical code 41872, when the actual service rendered was dental curettage.

What exactly is considered insurance fraud? Unfortunately, no simple "list" seems to exist. However, most authorities I questioned stated that they would know it if they saw it. After extensive research several years ago, I uncovered eight fraudulent practices that dental offices regualrly commit when dealing with insurance companies. (Note: Each state's statutes actually govern what constitutes fraud.)

Submitting a patient's claim to both a medical and a dental plan simultaneously - without letting each plan know about the other - is generally considered fraud. Also, billing for services not performed - such as billing for surgery when nonsurgical treatment was performed - would be considered fraud.

What about dental implants and TMJD treatment? A large number of states currently have some legislation stipulating that TMJD and "jawbone treatment" cannot be excluded by medical carriers. However, many gray areas exist that are in desperate need of clarification. Who may perform and bill for the treatment? A dentist? A physician? More importantly, where does a dentist go for answers to these questions?

In the past, dentists and dental fraud have been considered "small potatoes" for most fraud health-care units. Compared to the huge amounts of money usually involved in medical fraud, dental fraud amounts are miniscule. However, dentists involved in medical fraud are something else again.

The profession needs to have these issues clarified. The ADA has been active in promoting a dentist's right to noninterference in insurance "Estimates of Benefits" language. Medical/dental treatment and the role of the dentist also needs to be defined. Lawsuits and fraud cases after the fact are not the best way to address this problem!

It's Fraud!

  • Billing for services not performed
  • Upcoding
  • Waiving copayments
  • Waiving deductibles
  • Altering dates of service
  • Unbundling or improper use of codes
  • Misrepresenting patient identities
  • Not disclosing existence of additional or primary coverage

Carol Tekavec, RDH, is the author of the Dental Insurance Coding Handbook-2000, co-designer of a dental chart and an informed consent booklet, and a national lecturer. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com.

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