Navigating dental claim FWA: The impact of abused codes and claim splitting

The landscape of dental claims is fraught with complexities, where the misuse of specific dental codes and improper billing practices have become more prominent. From bone grafts to buildups, scaling, and root planing, improper billing and overuse of these codes for patients where such treatment is deemed unnecessary can negatively impact patient health and stimulate mistrust between payers and providers.

Among these payment schemes, overbilling and claim splitting have become common fraudulent practices that impact the integrity of dental payments. In 2023, dental expenditures reached $174 billion, accounting for more than 3% of total healthcare spending. As the dental industry continues to grow and evolve, these schemes can become difficult to identify, resulting in improper billing practices which drive up costs.

In this eBook, we highlight the top procedures that are frequently misused and offer insight into these trends by examining their causes, consequences, and the steps necessary to mitigate the effects of fraudulent and abusive dental billing practices. By understanding the nuances of these schemes, dental payers can foster a more ethical and efficient claims process, ensuring transparency for all stakeholders.

Commonly abused codes and their impact

Abusive billing practices often revolve around the misuse of certain dental procedure codes. These codes, when improperly applied, can result in inflated costs and undermine the integrity of the dental claims process. Some of the most commonly abused codes include bone grafts, non-surgical root canal obstructions, buildup, localized antimicrobial agents, and surgical extractions.  

Bone grafts

In 2024, Cotiviti dental clients were billed $14.7 million for bone grafts, a procedure often added to extractions without medical necessity. Following clinical review of the documentation, our experts revealed a savings of nearly $3 million, approximately 20% of the total billed amount by identifying and addressing improper billing for bone grafts.

Root canal treatments

The code D3331, used for treating root canal obstruction, is frequently billed alongside routine root canal treatments (RCTs) without sufficient evidence of an obstruction. In 2024, clients were billed $2.9 million under this code. After reviews, approximately 18.7% or $543,000 in improper charges were identified and saved.

Buildups

Buildups under crowns are another area prone to overbilling where providers must demonstrate that there was insufficient retention in a crown, which necessitates the need for an extra coronal restorative procedure. If documentation fails to demonstrate the necessity for a buildup procedure, clinical review can flag the claim. In 2024, clients were billed $52.8 million for buildups, with $8.4 million in improper charges identified and prevented—representing a savings rate of approximately 15.9%.

Gingivectomies and localized antimicrobial agents

Codes like D4381 pertain to the localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue. This code is used for each individual tooth when an FDA-approved antimicrobial agent is sub-gingivally placed into periodontal pockets of at least 5mm depth. In 2024, clients were billed $3 million for procedure code D4381. Clinical reviews ensured billing aligned with treatment guidelines, resulting in $208,000 in savings—reflecting a savings rate of approximately 6.9%.

Extractions

In 2024, procedure code D7210, associated with the surgical extraction of an erupted tooth, was billed at $121 million. Clinical reviews reclassified many of these cases to D7140, a less intensive procedure, resulting in $37.4 million in savings for clients, representing a savings rate of approximately 30.9%.

Scaling and root planing

Historically, scaling (D4341) and root planing (D4342) are highly abused codes. Over a three-year period from 2019 to 2022, Cotiviti clients were billed over $16 million for scaling and root planing (SRP). After reviewing the providers submitted records and verbiage for what constitutes the necessary requirements for the procedure, our clinical experts denied or suggested a re-code. This review saved our clients an average of 39% of their total dental spend for SRP.

In total, expert review of commonly abused and overused codes resulted in over $55 million in savings for Cotiviti clients. These examples reveal the widespread financial impacts of abusive billing practices, underscoring the need for vigilance and robust review processes.

Claim splitting trends

Claim splitting occurs when dental providers separate a single claim into multiple submissions. While this can be legitimate for administrative reasons, it is often misused to manipulate reimbursement by dividing procedures typically performed in one visit into separate claims. This can be done by using different dates of service, billing lines, or provider identification. Improper claim splitting is used to bypass reimbursement limitations, inflate payments, or obscure the true nature of services. Understanding this practice is important to help ensure payment integrity for both dental providers and insurers.

Some common patterns and their implications include:

• Multiple Extractions: Claims for multiple extractions on the same date of service are split into separate submissions to avoid rules that apply to four or more extractions.
• X-Rays and Root Canals: X-rays are submitted on a separate claim line from the root canal procedure to bypass review.
• Prophylaxis (D1110) and periodontal maintenance (D4910): These are often billed on the same date of service but under separate claims.

Proper claim splitting can benefit a patient with dual coverage or reflect true dates of service for treatment provided over multiple appointments. But often, this process is misused, leading to overpayments and obscuring the necessity of services. This can increase the risk of investigations, audits, or fraud allegations, and further complicate the dental claims landscape.

Key recommendations

Prevention of abusive billing requires a proactive approach rooted in education, review, and system improvements. Dental payers can take actionable steps to help mitigate these practices.

Implement robust utilization reviews. Regular and thorough reviews of claims can identify patterns of abuse. For example, monitoring high-frequency use of specific codes like D3331 and D7210 can flag improper billing.

Enforce clear documentation requirements. Require dental providers to submit comprehensive documentation that justifies the procedures billed. For instance, buildups should only be reimbursed when evidence shows insufficient retention for an extracoronal restorative procedure.

Educate providers. Provide training and resources to dental providers on proper billing practices, including clear explanations of coding guidelines and payer policies.

Leverage advanced analytics. Utilize data-driven solutions to identify trends and anomalies in claims submissions. Advanced analytics can detect patterns like improper claim splitting or repeated overuse of certain codes.

Collaborate with providers. Work collaboratively with dental offices to establish clear communication channels and resolve billing discrepancies amicably.

Monitor claim splitting practices. Develop systems to track and analyze claim splitting patterns, ensuring they align with administrative and medical necessity guidelines.

Abusive billing practices not only inflate costs but also erode trust between dental providers and payers. By addressing trends in overbilling and claim splitting through systematic reviews, education, and collaboration, dental payers improve payment integrity and help alleviate provider abrasion. Adopting these measures not only protects financial resources but also ensures a fair and transparent claims environment, ultimately benefiting both providers and patients.