FWA Insights: Managing FWA for dental claims

Every health payer should be on the alert for fraud, waste, and abuse (FWA), but for payers in dental services, “at risk” dollars are considerably lower than those of medical services. As a result, many dental payers have developed a bad habit of overlooking incorrect billing. But overlooking even minor overpayments is a slippery slope, which can lead to a two-fold problem: providers continuing to bill inappropriately—and possibly more often—and patients not receiving the full benefit from their dental plan.

In this latest installment of Cotiviti FWA Insights, we will walk through several examples of FWA specific to dental services.

Dental claim waste

A major problem for dental payers that often goes unchecked is waste, or billing for medically unnecessary services. Waste in dental services not only affects the dental plans, but it inaccurately deducts from their members’ yearly maximum benefit, potentially leaving insufficient funds for other necessary procedures.

An example of waste in dentistry is billing for a buildup while preparing a tooth for a crown when there is enough tooth structure left to support the crown. According to Current Dental Terminology (CDT), a buildup is a procedure to build up the coronal tooth structure when there is insufficient retention for a separate extra coronal restorative procedure. Cotiviti’s licensed dental professional specialists review x-rays to determine if enough tooth structure exists to verify whether a buildup was medically necessary. Cotiviti has identified over $4 million in wasted dollars for our clients in 2021 alone by reviewing the x-rays and chart notes for procedures identified by our algorithms as potentially wasteful.

Another problem that falls under waste for dental plans is in coding errors, generally made by the provider or billing department. A common error is billing for a procedure that, according to CDT, is included in another procedure also billed on the same date of service. While these could be unintentional mistakes, they must be reviewed for correct reimbursement and accurate patient history.

Cotiviti’s dental accuracy algorithms and reviewers saved one of our clients more than $700,000 in 2021 by catching unbundled procedures and other errors. Such mistakes can be caught by adding a final filter of automated editing to prepay claims set up specifically to catch errors. This helps reduce the need to chase overpayments, which is costly and often ineffective.

Dental claim abuse

Abuse typically involves acts that are inconsistent with identified acceptable and legitimate practices. This can result in additional and unnecessary costs to the payer, as well as possible injury to patients, who may suffer from a lack of needed care, incorrect care, or deficient care as a result. Over-coding procedures falls under the category of abuse. Examples of over-coding include billing for a higher extraction code when the lower code is more in line with the actual process per extraction codes contained in CDT. The higher code is generally reimbursed at a higher rate, thus using more of the patient's available dental plan benefit.

Recently, a Cotiviti dental consultant reviewed a claim for a full mouth extraction where extensive decay was noted. However, after reviewing the x-rays, our consultant could also see significant bone loss around numerous teeth. Her determination was to allow six extractions at the higher code, but the remaining 19 extractions with the bone loss were suggested to reimburse at the lower code, saving our client more than $5,500 on one claim.

Another example of abuse occurs when scaling and root planning is billed but does not meet the criteria set forth by CDT. If the patient only needs a regular cleaning but is subjected to a scaling and root planning procedure, which has a much higher reimbursement, the provider has committed abuse.

These and other highly abused codes have been identified through a postpay review of provider patterns. Using these results, Cotiviti built certain codes into our algorithms for procedures identified as having the highest potential for abuse. Our licensed dental consultants then manually review the provider’s records before payment to determine if abuse is occurring. Cotiviti saved our clients over $8 million in 2021 through this prepay review of highly abused codes.

Dental claim fraud

Fraud hinges on intent: healthcare workers knowingly working outside of accepted standards for their own financial gain. Some common fraud examples include billing for services not rendered, misrepresenting dates of service, diagnosing unnecessary or incorrect treatment, or misrepresenting the identity of the patient. While these aren’t limited to dentistry, spotting nefarious intent within inappropriate claims must be done right away before unwarranted payment escalates.

In one dental fraud case, Cotiviti’s dental investigator discovered that a dentist billed Medicaid $1.3 million for services not performed, upcoding teeth extractions, and submitting false bills to Medicaid. The dental investigator and her team performed an onsite audit at the provider’s private practice and determined within the first hour that this dentist was committing blatant fraud. The fraud was reported to CMS and other federal stakeholders and action was taken against the provider. The provider agreed to repay triple the damages and was sentenced and served five years in federal prison.

Best practices to avoid dental FWA

To avoid reimbursing inappropriate claims, plans must stay vigilant to the latest schemes and highest recurring errors within dentistry. Here are a few recommended best practices:

• Validate procedures that have a higher likelihood of FWA. Applying advanced algorithms to claims before they’re paid can automatically deny black-and-white, small-dollar issues while flagging gray-area claims that are most likely to be found improper. Flagged claims should be reviewed before payment with the help of a licensed, experienced dental professional, who can look at the provider's records and x-rays to decide if the procedures were medically necessary and appropriate.
• Review not only the claims, but the provider’s pattern of behavior. For instance, does the provider bill substantially higher code extractions than his peer group? Stay vigilant when it comes to recurring problematic patterns.
• Stay current on industry-wide vulnerabilities. Include providers who meet certain patterns of behavior in an enhanced review algorithm of their prepay claims for specific procedure codes that have been identified as wasteful and highly abused.