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Viewing:  Jun 20, 2019

Are You Protecting Your Dental Practice From Fraud?

By:  Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content

With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and billing practices. When payers identify the activities they deem "suspicious" or "unusual" it provides insight on the provider side that can help them prevent such behavior through changes and updates to their compliance plans. Some odd or suspicious billing practices that increase the chance for investigation were identified as: 

  • Billing an unusually high number of just one or two services instead of a variety of service 
  • Claims resubmissions with only the dates changed following a previous denial for dates of service outside of coverage period or when the services billed are in excess of the plan year maximums.
  • Billed services not supported by dental x-rays

Fraud costs taxpayers millions of dollars and puts patients in harms way. Providers need to protect their reputations and practices by maintaining up-to-date coding and billing information that can be easily accessed and used to maintain a comprehensive compliance plan. Our specialty-specific Reimbursement Guides (RGs) provide information specific to the newest code additions, deletions, and revisions for the current year our Dental RG offers dental to medical coding crosswalks, coding, billing and auditing tips, and so much more.

Additionally, Find-A-Code offers an online subscription to access all of the codes, Medicare guidelines, commercial payer policy information, as well as additional information that is vital to keep up-to-date and compliant. Check out our subscription plans and the Reimbursement Guides specific to your specialty today.





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