Home Practice ManagementOperations Are You Committing Insurance Fraud… Unintentionally?

Are You Committing Insurance Fraud… Unintentionally?

by Steven Anderson

When working with a dental team recently to improve their collections through better financial arrangements and insurance billing, they were shocked to discover they were committing insurance fraud. Many teams do. Most don’t know they are.

How about you?

The first rule of insurance coding and billing is: Code and bill for what you do, when you do it. Never use a code for something you did not do, even if someone at the insurance company tells you to!

It’s Not a Cleaning if That’s Not What You’re Doing!

One of the most common mistakes is coding a 4910 Periodontal Maintenance appointment as an 1110 Prophylaxis. The rational that most use is that insurance will not cover more than two 4910’s a year so they code the additional hygiene appointments during the year as 1110 or they alternate the two codes. Technically speaking, that is fraud. You code for what you are doing, not for what insurance may or may not pay for. In an audit situation, if you have coded for something other than what you actually did, it can be considered fraud. The correct way to code would be a 4910 for each visit with a request in the narrative that the alternative D1110 be substituted if D4910 is not allowed. That way you have coded accurately and the insurance company can decide if the substitution is allowed.

Write-offs may be fraud.

Occasionally we find practices that file insurance and never charge the patient their portion. Provider contracts require the patient portion to be charged and collected. Anything short of that can be considered fraud. If you are a dentist and you tell your team not to worry about collecting the patient portion, you are running a huge risk. If you are a team member being told to do so, you are a party to the crime! Don’t do it. It puts the practitioner and the entire practice at risk. If you signed the agreement, so what you promised to do.

Dates matter

Bill procedures only as they have been completed. When you submit for a procedure that was completed in two appointments, like a crown, record the “prepped” date and file the claim on the “delivery” date. Submitting a claim for a completed crown before it has been seated can result in a mess and can be considered fraud. Code what you do and when you do it.

New Communication, New Perspective

Maximizing patients’ insurance is always a goal for both the practice and the patient. Patients frequently ask, “Will my insurance cover all of this?” Consider the right verbiage when responding by avoiding what we call “limiting language.” Do not respond with, “Your insurance will only cover…” Instead, say, “Your insurance savings to help with your treatment is estimated to be…” Help patients reframe their insurance as a savings benefit not a 100% payment policy.

Maximum Reimbursement*

Insurance coding and billing is just one part of your total financial arrangements strategy. Making sure you are getting paid for the service you are providing honestly and ethically and providing the patient with the best value is always the objective.

*To discover the missed opportunities in the financial arrangements system in your practice, schedule a Maximum Reimbursement Analysis from the Total Patient Service Institute at www.totalpatientservice.com/moneyback or call 1-877-399-8677.

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