Unforced Private Insurance Billing Errors By Dentists Can Lead To Significant Losses and Liability. Avoid These 6 Common and Costly Mistakes.
Over the years, countless healthcare companies and practitioners have been fined, sanctioned, or even jailed for fraudulent or illegal billing practices involving Medicare and Medicaid or equivalent state programs. Such transgressions against government payors are vigorously prosecuted by the U.S. Department of Justice and their state-level counterparts, primarily under the federal False Claims Act (FCA). However, the FCA only applies to fraud against the government, not activities that defraud private insurers.
Unlike care and services provided by other practitioners, most of the services offered by dentists are not covered by Medicare or Medicaid, meaning that the vast majority of their billing and reimbursement activities involve private payors. Given the government’s focus on the FCA and fraud against Medicare and Medicaid, dentists may be under the mistaken impression that they can be less vigilant and compliant and more lax in their practices when billing private insurers. This can be a costly, disruptive, and damaging misconception.
Just like whistleblowers can report provider billing fraud and initiate actions under the FCA, those who discover and identify fraudulent billing practices by dentists involving private insurers can do the same under state specific laws, such as the Illinois Insurance Claims Fraud Prevention Act in Illinois. Of course, insurers themselves have their own contractual and other remedies for billing misconduct by dentists under their participation agreements.
Many, if not most, insurance billing mistakes by dental practices are just that – errors made without any fraudulent or nefarious intent. But, as is often said, ignorance of the law is no excuse. Such is the case with insurance billing by dentists.
Here are six of the most common billing errors by dentists when making claims or seeking reimbursement from private payors:
Billing For Services Not Rendered/Double Billing
Billing fraud doesn’t get any simpler than submitting claims for reimbursement for services that were never provided to the patient. Similarly, billing the insurer twice for the same services is Fraud 101.
Inadequate Documentation
One prevalent mistake made by dentists is insufficient documentation of procedures and patient records. Proper documentation is crucial for insurance claims, and failure to maintain detailed records can lead to claim denials or even allegations of fraud. Dentists should ensure that each patient's file includes comprehensive details about the diagnosis, treatment plan, and any communication with the insurance company.
Upcoding and Unbundling of Services
Dentists and other practitioners may try to maximize their reimbursements by improperly coding and billing procedures and services.
Upcoding occurs when a dentist inflates requests for reimbursement by submitting false medical codes—that is, billing for diagnoses and services that are more serious and expensive than the services rendered. Another form of improper medical coding and fraud is unbundling, also referred to as “fragmentation.” This occurs when a dentist fragments or unbundles billing codes to receive a higher aggregate reimbursement amount.
Both upcoding and unbundling are illegal under federal and state laws and regulations and can result in hefty fines, loss of licensure, and even criminal charges. Dentists should carefully review billing codes to ensure accurate representation of the provided services.
Ignoring Preauthorization Requirements
Some dental procedures necessitate preauthorization from insurance companies before treatment. Ignoring these requirements and proceeding without obtaining preauthorization may lead to denied claims and disputes. Dentists should familiarize themselves with the specific preauthorization requirements for various procedures and ensure compliance to avoid legal complications.
Billing Inaccuracies
Submitting inaccurate or false information on insurance claims is a serious legal offense. Whether intentional or due to oversight, inaccuracies in billing can lead to allegations of fraud, resulting in severe consequences such as fines, imprisonment, and damage to professional reputation. Dentists must implement rigorous quality control measures to ensure the accuracy of all billing information.
Waiving of Coinsurance or Copayments
If you think it is savvy or generous to waive patients’ deductibles and copays, you could quickly find that it is neither. Dentists cannot waive patients’ deductibles or copayments as it drives up premium costs for policyholders and could encourage patients to request unnecessary treatments. This practice constitutes illegal overbilling and is considered fraudulent.
Contact Us With Any Insurance Billing Questions or Concerns
As noted, most of the acts that lead to legal and contractual problems with billing private insurers are mistakes, not attempts to game the system and commit fraud. But unforced errors can be just as costly as intentional misconduct. If you have any questions or concerns about your billing practices or would like assistance establishing policies and protocols to minimize the chances of billing problems, please give us a call. At Grogan, Hesse & Uditsky, P.C., we focus a substantial part of our practice on providing exceptional legal services for dentists and dental practices, as well as orthodontists, periodontists, endodontists, pediatric dentists, and oral surgeons. We bring unique insights and deep commitment to protecting the interests of dental professionals and their practices and welcome the opportunity to work with you.
Please call us at (630) 833-5533 or contact us online to arrange for your free initial consultation.
Jordan Uditsky, an accomplished businessman and seasoned attorney, combines his experience as a legal counselor and successful entrepreneur to advise dentists and other business owners in the Chicago area. Jordan grew up in a dental family, with his father, grandfather, and sister each owning their own dental practices, and this blend of legal, business, and personal experience provides Jordan with unique insight into his clients’ needs, concerns, and goals.
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