Dental insurance fraud.

As a representative of the CDHA, this advisor attended a meeting of the Canadian Health Care Anti-Fraud Association in June. The meeting focused on dental fraud--from minor infractions to highly questionable billing practices.

Two common infractions cited are the waiving of co-pay "the difference between the fee charged and what the insurance pays" and an exaggeration of service in terms of time spent. More serious forms of dental fraud include changing the dates of service, charging for services that are not performed and substituting covered services for non-covered services. Another topic of discussion is the increase in incidence of dental fraud by dental office staff. Investigations have determined that this is often committed by the dental receptionist, the staff person with the greatest access to client files and billing information. The offender submits fraudulent claims for people who are not clients of the practice or who are family members.

Of particular interest to dental hygienists were the number of examples of dental fraud which pertain to the services and treatment that dental hygienists typically provide in a dental office. These include radiographs, scaling and root planning procedures. One of the most frequently exaggerated procedures cited is scaling units. The dental insurance carriers become suspicious when they see a provider who routinely charges for multiple scaling units on all clients, especially for those under the age of eighteen. Another suspicious practice is a provider who maximizes or "shops" the fee guide. This provider may submit insurance claims that match plan maximums with respect to the number and timing of radiographs and scaling units.

To compound the problem, the insurers see an increase of assignment of benefits to the providers. Therefore, the client as a non-participant in the process may not even see the dental claim form that is submitted. Clients of these offices report that the treatment codes and fees were never explained and that they did not receive a copy of the treatment billed to the insurance companies.

As incidences of dental fraud increase, the insurance companies are becoming increasingly diligent in the detection and monitoring of offending practitioners. The insurance industry has responded to the increased incidence of dental fraud by instituting the following procedures:

1. Increased third party audits.

2. Insistence on reasonable and customary fees, based on best practice guidelines.

3. Institution of watch lists, toll-free tips line, and monitoring of suspicious claims.

In addition, dental plan designers have made significant changes to dental plan design. In an effort to contain costs, rather than reduce health benefits, they are encouraging employees to participate more actively in their health coverage. There is a growing acceptance for "flex plans" and "health spending accounts" which permit the employee to decide where best to spend health dollars. On another note, as employers seek employee cost-cutting measures, approximately 17 per cent of Canadian employers have reported a reduction or elimination of health benefits for retirees.

What does this mean for dental hygiene practitioners who are submitting insurance claims?

1. Always adhere to best practice guidelines when assessing and initiating dental hygiene care.

2. Always document and sign your treatment notes.

3. Ensure that your treatment is appropriate and accurate in terms of time and service.

4. Ensure that your client understands and agrees to the treatment you provide, including a clear explanation of the service codes and fees.

5. Always provide your clients with a hard-copy of their treatment and fees.

6. Monitor staff access to client files.

What opportunities does this provide for independent practising dental hygienists?

1. An opportunity to promote dental hygiene care and oral disease prevention as a long-term cost-saving service.

2. An opportunity to practise effectively and efficiently according to dental hygiene standards of practice.

3. An opportunity to assume a leadership role as a primary oral health care provider.

As dental hygienists spread their entrepreneurial wings and establish independent practices, it is important to recognize that the onus to submit accurate insurance claims rests solely on their shoulders. Creating a practice environment where the needs of the client comes first and foremost will ensure high standards of care for the client and a business that is a growing source of pride for the dental hygienist owner.

CDHA's Independent Practice Advisor, Ann E. Wright