Financial losses due to fraud, waste, and abuse (FWA) are a major challenge for dental plans as overtreatment becomes a growing issue in the dental field. Overtreatment and other wasteful or abusive practices, which may be intentional or unintentional, have significantly impacted dental payers and patients directly in several ways: increased costs, unnecessary and even harmful procedures, and FWA that impacts the member’s plan benefits.

With $165 billion spent on dental treatments in 2022, and approximately 3–10% of these payments comprising FWA according to the National Health Care Anti-Fraud Association (NHCAA), these actions put strain on insurers with excessive claims for unnecessary treatments, making it harder to manage legitimate claims and threatening trust in both dentists and dental plans. By adopting automated solutions and professional review of dental claims, dental payers can combat these inappropriate practices while protecting their members and educating providers.

By adopting automated solutions and professional review of dental claims, dental payers can combat these inappropriate practices while protecting their members and educating providers.

Why FWA is prevalent in dental billing

Medical procedures that get billed to health plans often require pre-authorization based on the diagnosis of the patient’s medical issues presented. In dental practices, however, non-surgical procedures (such as crowns) get billed and coded at the discretion of the dentist without pre-authorization.

Dental practices are often owned by larger companies through consolidation and must meet goals to satisfy these stakeholders, sometimes mandating standardized treatment plans instead of working to develop a custom plan based on the needs of the patient. Occasionally, bad actors will even use inappropriate billing practices without informing the dental staff.

Patients with Medicare Advantage (MA) plans may be at a higher risk of overpaying for treatment that is unnecessary. Bad actors can take advantage of these patients due to the variety of benefits that can be used on dental care. Though some MA plans have restrictions, others have no limit to the amount that may be spent on procedures deemed essential by their provider. For example, one deceptive practice may be able to capitalize on a patient with a $2,000 dental limit and overtreat in order to collect the full amount.

Dental offices may also work with outside consultants that advise them on how to hit revenue goals without being aware of clinical and billing best practices, often resulting in overbilling. For example, if a staff member bills for a crown, they may also be told to bill for a build-up, even when the procedure is unnecessary—or in certain cases, even if it wasn’t performed in the first place.

The impact of FWA in dental billing procedures

FWA is estimated to cost the U.S. healthcare system hundreds of billions of dollars annually. Dental FWA contributes to this figure but represents a smaller portion compared to medical fraud. Overtreatment can inflate the cost of dental care exponentially. For a dental plan, this can translate into millions of dollars in improper payments to dentists every year depending on the size of their membership.

FWA drives up the overall cost of care, resulting in higher premiums for policyholders.

Individual cases of overtreatment such as unnecessary crowns or root canals can cost hundreds to thousands of dollars each. When multiple instances are aggregated, the financial impact on the dental payer is substantial.

FWA drives up the overall cost of care, resulting in higher premiums for policyholders. Additional administrative costs for auditing, investigating and resolving disputes further adds to the financial impact on dental payers.

Common FWA schemes in dental payments

Waste and abuse can take many different forms within dental billing and claims submission. Overtreatment, upcoding, and repetitive add-on procedures are some of the most evident forms of waste and abuse. Here are common examples of FWA often detected in dental claims:

• Add-on codes for crown procedures, which are categorized as abuse or fraud if the procedure was not performed.
• Upcoding, such as billing for a higher extraction code than warranted. 
• Overtreatment, such as performing unnecessary fillings. This can be especially damaging for patients’ teeth, considering that putting a crown on a healthy tooth will naturally weaken it and shorten its longevity. Periodontal procedures such as root planing and scaling are another common example of overtreatment.
• In a multi-dentist practice, different procedures may be billed under different providers’ names in an attempt to sneak FWA past the dental claim system and claim editors.

Combatting FWA with the right partner

While most dental plans already use a primary editor to catch duplicative claims, a second-pass system can investigate deeper with client-specified parameters without overwhelming dental plan staff. Dental prepay review after primary editing enables an automated review process to ensure claims are evaluated against standardized guidelines and best practices using advanced clinical and coding algorithms. For example, Cotiviti’s system flagged a treatment plan that was billed for $15,000. After further inspection and review of patient documents, the necessary treatment totaled only $1,800.  

If inappropriate add-on codes or upcoding are flagged in the second-pass system and validated for a recommended denial or down-coded payment, the need to pursue overpayment recovery is eliminated. When payment has already been made, postpay review can identify patterns to help determine the next steps, such as provider education or legal action in more serious situations.

While most dental plans already use a primary editor to catch duplicative claims, a second-pass system can investigate deeper with client-specified parameters without overwhelming dental plan staff.

Claim editing is further bolstered by dental utilization review, which includes the direct analysis of x-rays and documentation to verify past treatment. This in-depth analysis can confirm if a procedure should have been performed based on the individual patient's condition. Specific codes are scrutinized for clinical and medical necessity, while other codes are reviewed for appropriateness.

Detecting and stopping FWA directly impacts dental plan performance, reducing losses from FWA, discouraging overtreatment, and protecting members’ financial benefits.

Ideally, each dentist will work with a patient individually to create a treatment plan that fits best for their health, financial situation, and dictated goals. By implementing a strong payment integrity program, plans can improve outcomes for all stakeholders in dental care.