by Christine Taxin
July 23rd, 2019
There is an ever-increasing number of dental claims that 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