Dental overbilling is a significant concern that affects patients, insurance companies, and the overall integrity of the healthcare system. This improper practice involves a provider charging an unreasonable or excessive amount for a service, often resulting in inflated costs for the patient or the insurer. Understanding the difference between a high fee and a fraudulent charge is the first step toward protecting yourself financially and helping to maintain ethical standards in oral health care. This information clarifies exactly what dental overbilling entails and provides actionable guidance on how patients can identify and address suspected instances of fraud.
Defining Dental Overbilling
Overbilling in dentistry refers to the unethical practice of submitting claims for more than the actual value or cost of services provided, often targeting insurance plans for higher reimbursement. This practice is distinct from a dentist simply charging high fees, which is a matter of market rate, or balance billing, which is charging the patient the difference between the actual charge and the insurer’s allowed amount. True overbilling involves dishonesty or misrepresentation in the billing process itself, aimed at financial gain.
It is important to recognize the difference between intentional fraud and an administrative mistake. Fraud requires an element of intent, deception, and unlawful gain, such as knowingly submitting a false claim. Administrative errors, like a simple coding mistake or data entry issue, are unintentional and should be correctable by the dental office. Overbilling specifically refers to the deliberate manipulation of the billing system, which has legal consequences for the provider and financial repercussions for the patient and insurer.
Common Methods of Fraudulent Billing
One of the most common schemes is upcoding, which involves billing for a more expensive procedure than the one actually performed. For example, a dentist may perform a simple, routine filling but bill the insurance company for a complex, multi-surface restoration that carries a higher reimbursement rate. This misrepresentation allows the practice to receive a larger payment than is warranted by the service delivered.
Another frequent tactic is unbundling, which occurs when a provider separates procedures that are typically billed together as a single unit. A comprehensive procedure is broken down into its individual components, and each part is billed separately. This results in a higher total charge than the single, inclusive code would have generated, fragmenting the billing process solely to maximize revenue.
Providers may also engage in billing for services not rendered, often called phantom billing, where they submit claims for appointments or procedures that never took place. Charging for medically unnecessary procedures is another form of fraud, where a patient is advised to undergo extensive work, such as multiple crowns, that is not clinically required simply to exhaust their annual insurance maximum.
How Patients Can Detect Overbilling
The most effective tool a patient has for detecting possible overbilling is the Explanation of Benefits (EOB) document sent by the dental insurance company. The EOB is not a bill but a summary of how your claim was processed, detailing the services billed, the amount the dentist charged, and the amount the insurer paid. Patients should carefully compare the services listed on the EOB against the services they actually received during their visit.
Specific details to check include the dates of service and the procedure codes, known as Current Dental Terminology (CDT) codes. If the EOB lists a complex procedure code, such as a surgical extraction, but you only received a simple tooth removal, this suggests upcoding. If you notice separate, small charges for services that seemed to be part of one overall treatment, this could indicate unbundling.
Patients should question extensive treatment plans, especially those that involve costly or multiple procedures. Seeking a second opinion from an unaffiliated dental professional can confirm whether the proposed work is genuinely necessary for your oral health. If a discrepancy is found, the first step is always to contact the dental office to ask for clarification, as the issue may be a simple, unintentional billing error.
Reporting Suspected Dental Fraud
If a patient suspects intentional fraudulent activity after reviewing the EOB and communicating with the dental office, the primary reporting channel is the insurance carrier. Insurance companies have dedicated fraud hotlines or secure electronic forms to submit reports of potential fraudulent activity. They possess the necessary resources and motivation to investigate claims, as they are the direct financial victims of the fraud.
Before making a report, it is important to gather and organize all relevant documentation. This includes copies of the EOB, the dental office’s billing statement, any treatment plans provided, and detailed notes about the dates and services you received. This evidence is crucial for investigators to evaluate the matter.
Patients can also report misconduct to their State Dental Board or a state’s consumer protection agency. State boards regulate the licenses of dental professionals and can investigate issues related to professional conduct and quality of care. In cases of significant, large-scale fraud, federal or state law enforcement agencies may become involved to prosecute criminal activity under laws like the False Claims Act.