Unforced Private Insurance Billing Errors By Dentists Can Lead To Significant Losses and Liability. Avoid These 6 Common and Costly Mistakes.

Jordan Uditsky • March 6, 2024

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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Whatever shortcomings and deficiencies there may be in the dynamic between dental practices and insurance companies, their distinct roles in patient care are not among them. While dentists certainly want to maximize reimbursements for the services they provide, they are not beholden to insurers and remain in a position to advocate for their patients and challenge an insurer’s cost-related decisions without fear of retribution. But a recent unprecedented move by Delta Dental in Wisconsin threatens to upend this relationship model and has raised serious concerns among industry groups, patient advocates, and regulators about conflicts of interest, competition, and provider independence. Over the summer, Delta Dental announced that it had acquired Cherry Tree Dental, which owns and operates 31 clinics, 25 of which are in Wisconsin. The American Dental Association (ADA) is among several organizations that have vocally opposed the transaction. As the ADA wrote shortly after the deal was announced: When an insurance company becomes both health care provider and insurance payer, questions arise regarding potential conflict of interest. From a business standpoint, dental insurance companies seek to minimize cost and maximize profit. As a result, patients may find their treatment options limited to what is most cost-effective for the insurer, not necessarily what is most effective for their oral health. The ADA believes that the health interests of patients are best protected when dental practices and other private facilities for the delivery of dental care are owned and controlled by a dentist licensed in the jurisdiction where the practice is located. In November, the ADA filed a letter with the Wisconsin Office of the Commissioner of Insurance expanding on its concerns and opposition, including worries about provider independence in making care decisions: Direct ownership by Delta Dental could compromise dentists’ ability to advocate for patients. In traditional arrangements, dentists can appeal plan decisions regarding patient care or choose to leave a network if plan policies are overly restrictive. However, the ADA warned that when dentists are employed by the payer, challenging cost-related decisions could label them as “problem employees,” potentially discouraging proper patient care. The potentially anti-competitive effects of such arrangements were also raised by the ADA, which noted that “Delta Dental’s acquisition could influence agreements, business practices, and fee schedules between Cherry Tree and other payers, potentially creating unfair competition.” In addition to the ADA, the acquisition has drawn concerns from the Wisconsin Dental Association, the American Economic Liberties Project, and the Alliance of Independent Dentists. The fallout of this acquisition, if consummated, could ripple through other markets, potentially leading to a seismic shift in the provider-insurer landscape. We will continue to monitor developments and provide updates as warranted. We Focus on You So You Can Focus on Your Patients 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. This blend of legal, business, and personal experience provides Jordan with unique insight into his clients’ needs, concerns, and goals. 
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Whether you are the associate or the practice owner in such an anticipated transaction, you should consult with an experienced dental practice attorney to understand your options and determine which structure provides you with the most value. Your discussions with your attorney will likely include some or all of these common dental associate buy-in arrangements: Cash Purchase A cash purchase is the most straightforward buy-in model. With either cash on hand or through financing (the more likely scenario), the associate purchases an agreed-upon percentage of the practice (for example, 25% or 50%) for a lump sum based on the appraised value of the practice. That appraisal will likely use metrics such as collections, earnings before interest and taxes (EBIT), or a percentage of annual gross revenue. The main advantage of a cash purchase is its simplicity and immediacy. The associate becomes an owner right away, while the practice owner receives a clean and full payout for the equity sold. However, obtaining the needed financing may be easier said than done for an associate dentist, and a large cash payout may also come with unwanted tax ramifications for the owner. Buy-in documents for a cash purchase should address governance rights, profit distribution, and exit mechanisms. They should also define what happens if an associate departs, how future buyouts are valued, and whether non-compete or non-solicitation covenants apply. Installment Sale An installment sale allows the associate to purchase equity over time, making periodic payments instead of an upfront lump-sum payment. After the practice value is determined, the associate agrees to buy a certain percentage of ownership through regular payments (e.g., monthly or quarterly) over several years. Payments may include interest, and ownership may be transferred incrementally or upon full payment. This is a good option for associates who do not have the means for a full cash buy-in immediately. For owners, this arrangement provides a steady income stream – so long as the associate does not leave before completing payments. That is why the documentation should clearly outline the timing of ownership right transfers and provide robust default remedies, such as forfeiture of prior payments or reversion of ownership interests. Sweat Equity In a sweat equity buy-in, the associate essentially cashes in their years of service, earning ownership over time based on their contribution to the practice’s growth or profitability rather than through an immediate cash investment. In a typical sweat equity arrangement, the associate receives equity credits or options tied to measurable performance benchmarks, such as production levels, collections, or tenure. Once those targets are met, a portion of ownership is granted or sold at a reduced price. This structure enables talented but liquidity-challenged associates to become owners without initial financial strain. It also incentivizes them to grow the practice and stay long-term. Shadow Account (a/k/a Phantom Equity) As I discussed in detail in this post , a shadow account (also known as a phantom equity plan) is an increasingly popular buy-in model, especially when the owner is not yet ready to transfer real equity but wants to reward the associate as if they were an owner. In this model, the associate receives the right to cash payments equal to the value of the shares at a specified later date or distribution event. That value can be established through an appraisal or an agreed-upon formula. The selected events that give an associate a right to a payout can include such things as achieving performance goals, termination, or retirement. There are two types of shadow account/phantom stock plans. In an "appreciation only” plan, the cash payout upon vesting does not include the value of the underlying shares, only the increase in value of that stock since it was granted. In a “full value” plan, the practice pays both the underlying value of the stock and the amount the stock has appreciated while held by the associate. Like actual stock, phantom stock has a defined value and tracks the practice’s performance, but an associate holding phantom stock typically does not have either minority shareholder rights or voting rights in the practice. This makes phantom stock plans attractive for owners who want to provide associates with a sense of equity ownership without giving up any actual control. The practice has broad discretion and flexibility in designing the plan, including valuation formulas and vesting conditions, and the administrative burdens are less than for traditional stock option plans. As noted, the “best” buy-in structure depends on the unique goals of both parties. No matter which model is ultimately adopted, well-crafted documentation, preceded by careful consideration and consultation with counsel, is essential. That is because these deals do more than just transfer ownership - they can lay the foundation for a stable, profitable partnership that preserves the practice’s legacy and rewards everyone’s investment, financial or otherwise. We Focus on You So You Can Focus on Your Patients 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. 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