Illegal dental billing practices: what crosses the line, and how honest offices drift
Ten billing practices treated as overbilling or insurance fraud, the ADA rules and statutes behind them, and the everyday posting habits that lead a careful office toward them.
By Dr. Salem Sayegh, general dentist, Glendora, California ·
The short answer: a dental billing practice is illegal when it misrepresents something to the insurer in order to be paid: what was done, when it was done, who did it, or what the patient is really being charged. The most common forms are billing for services not rendered, upcoding, unbundling, changing the date of service and waiving copayments without telling the plan.
This is general information from a practicing dentist, not legal advice. Rules differ by state and by plan contract. For a decision about your own office, talk to a health care attorney.
Ten practices that cross the line
| Practice | What it looks like | Why it is a problem |
|---|---|---|
| Billing for services not rendered | A claim for a procedure that was never done, or done on a different tooth. | A false claim. |
| Upcoding | Reporting a higher-paying code than the treatment performed. | Misdescribes the procedure to get a larger payment (ADA 5.B.5). |
| Unbundling | Splitting one procedure into separately billed parts. | Bills more than the procedure is worth under the code set. |
| Changing the date of service | Moving the date into a new benefit year, or past a waiting period or frequency limit. | A false statement made so a benefit will pay (ADA 5.B.4). |
| Waiving the copay without telling the plan | Accepting the insurance payment as payment in full while billing the full fee. | Makes the fee look higher than what is really charged (ADA 5.B.1). |
| Charging insured patients more | One fee for cash patients and a higher one when a plan is paying. | The ADA calls this overbilling (5.B.2). |
| Making a non-covered procedure look covered | Describing a cosmetic procedure as a restorative one. | Misdescribes the procedure on the claim (ADA 5.B.5). |
| Double billing | Sending the same service to one insurer twice, or to two insurers as if each were primary. | Collects more than once for one procedure. |
| Altering the record to support a claim | Changing chart notes, dates or radiographs after the fact so a claim looks justified. | Falsifies the evidence the plan relies on. |
| Misstating who provided the care | Billing under a credentialed dentist for work done by one who is not in the network. | Misrepresents a fact the plan uses to set payment. |
What the ADA Code says
Section 5.B of the ADA Principles of Ethics and Code of Professional Conduct is one sentence long: dentists shall not represent the fees being charged for providing care in a false or misleading manner. Six advisory opinions apply it:
- 5.B.1, waiver of copayment. Accepting a plan's payment as payment in full, without disclosing that the patient portion will not be collected, is overbilling.
- 5.B.2, overbilling. Raising a fee solely because the patient has a dental benefits plan is unethical.
- 5.B.3, fee differential. The fee for a patient without benefits is the dentist's full fee, and that is the fee to report to every carrier.
- 5.B.4, treatment dates. Reporting incorrect dates to help a patient obtain benefits is a false representation.
- 5.B.5, dental procedures. Misdescribing a procedure to get a greater payment, or to make a non-covered procedure appear covered, is a false representation.
- 5.B.6, unnecessary services. Recommending or performing unnecessary procedures is unethical.
The laws behind it
- Federal health care fraud, 18 U.S.C. 1347. Applies to any health care benefit program, private dental plans included. Up to 10 years in prison.
- False Claims Act, 31 U.S.C. 3729. Applies to claims paid with government money, which includes Medicaid dental programs such as Medi-Cal Dental.
- California Penal Code 550. Makes it a crime to knowingly present a false or fraudulent claim for a health care benefit.
- California Business and Professions Code 810. Makes the same conduct unprofessional conduct and grounds to suspend or revoke a license.
Other states have their own insurance fraud statutes and dental practice acts with similar provisions.
What is not fraud
| In-network contractual write-offs | Required by the plan contract. This is the difference between your fee and the allowed amount. |
|---|---|
| One full fee, discounted by contract | Reporting your full fee on every claim and accepting a negotiated fee from a plan is how PPO participation works. |
| Alternate benefits | A plan paying for a less expensive procedure than the one performed is the plan’s rule, not the office’s misstatement. Report what you did. |
| Correcting an honest mistake | A corrected claim, or a refund of an overpayment, is the remedy and not the offense. |
How honest offices drift into trouble
Most dentists will never knowingly send a false claim. The risk I see in ordinary practices is quieter. It comes from posting habits that, repeated for long enough, add up to one of the patterns above.
- The deductible that never gets billed. The plan pays less than expected, the front desk writes off the difference to close the claim, and the patient is never asked for it. Done routinely, that is a copay waiver nobody decided on.
- Write-offs on the wrong plan. An in-network adjustment is taken on an out-of-network claim. The patient's share disappears from the ledger.
- Credit balances left sitting. A payer overpays, or pays twice, and the credit stays on the account. Keeping money you know is not yours is its own problem. For Medicaid programs, federal law requires reporting and returning an overpayment within 60 days of identifying it.
- The date typed from memory. A claim is created days after the visit with the wrong date of service.
- Codes chosen by habit. The same code goes out for every case of a kind, whether or not the chart supports it.
None of these is a scheme. Each is what happens when posting is done in a hurry by someone covering three jobs. The protection is boring: post every line of every EOB, bill every patient balance the EOB shows, refund every credit, and reconcile deposits so mistakes surface in days and not at an audit. How to read a dental EOB sets out that posting order.
Where software helps, and where it cannot
Software will not make a dishonest office honest. What it can do is remove the drift. Sai for Dentists posts the payment, the contractual write-off and the patient balance exactly as each EOB states them, the same way every time, and matches the total to the bank deposit. Denials, takebacks and anything that does not add up are flagged for a person. It does not choose procedure codes and it does not decide what to bill. Those stay with the dentist, where the responsibility already sits.
California offices can also read the state's rules on overpayment requests and payment deadlines.
Sources
- American Dental Association, Principles of Ethics and Code of Professional Conduct, section 5.B and advisory opinions 5.B.1 to 5.B.6.
- American Dental Association, Assuring Accuracy of Claims as a Treating Dentist.
- HHS Office of Inspector General, guidance on upcoding and unbundling.
- 18 U.S.C. 1347; 31 U.S.C. 3729; 42 U.S.C. 1320a-7k(d).
- California Penal Code 550; California Business and Professions Code 810.
Common questions
What are illegal dental billing practices?
They are ways of misrepresenting a claim to an insurer to obtain payment that is not owed. The common ones are billing for services not provided, upcoding, unbundling, double billing, changing the date of service, waiving the patient’s copayment without telling the plan, and charging insured patients a higher fee than uninsured ones. An honest coding or clerical mistake that is corrected is not fraud; fraud involves knowing misrepresentation.
Is it illegal for a dentist to waive a copay?
Routinely waiving the patient’s portion while billing the plan the full fee, without telling the plan, is treated as overbilling. The ADA Code of Professional Conduct says so in advisory opinion 5.B.1, and insurers and prosecutors treat it as a misrepresentation of the fee. An occasional, documented write-off for a patient in real financial hardship is a different matter, but check the plan contract and ask counsel.
What is upcoding in dental billing?
Upcoding is reporting a CDT procedure code that pays more than the code for the treatment performed. Reporting a surgical extraction for a simple one, or scaling and root planing for a routine cleaning, are the standard examples.
What is unbundling in dental billing?
Unbundling is billing separately for steps that are part of a single procedure, so that the total paid is higher. Charging separately for local anesthesia, or for a step the procedure code already includes, is the usual example.
Can a dentist change the date of service on an insurance claim?
No. The date on the claim must be the date the treatment was performed. Moving it so that a benefit year, a waiting period or a frequency limit works in the patient’s favor is a false statement on the claim. The ADA Code addresses it in advisory opinion 5.B.4.
What are the penalties for dental insurance fraud?
Federal health care fraud under 18 U.S.C. 1347 covers private dental plans as well as government programs and carries up to 10 years in prison. In California, Penal Code 550 makes a false health care claim a crime, and Business and Professions Code 810 makes it grounds to suspend or revoke a dental license.
What should a patient do about a suspicious dental bill?
Compare the office’s statement with the explanation of benefits from your plan: the procedures, the dates and the amount you owe should match. Ask the office to explain any difference. If it cannot, contact your plan’s fraud line. In California you can also file a complaint with the Dental Board of California.