ISSUE BRIEF: Addressing Fraud & Abuse in Dentistry

Issue Brief: Addressing Fraud and Abuse in Dentistry

Fraud, waste, and abuse in dentistry can increase costs for dental plans, employers, and consumers while exposing patients to unnecessary or inappropriate treatment. While the vast majority of dentists provide ethical, high quality care, fraudulent billing practices, overtreatment, and improper claims submissions remain challenges across both commercial and government funded programs. This issue brief outlines how fraud and abuse occur in dental care, the tools dental plans use to detect and prevent improper payments, and why collaboration across stakeholders is critical to protecting patients and maintaining the integrity of the dental benefits system. 

Background

Understanding fraud, waste, and abuse in dentistry

Dental fraud occurs when a provider intentionally misrepresents treatment or billing information in order to receive unauthorized payments. Common examples include billing for services not rendered, misrepresenting the date or type of service provided, unbundling procedures, upcoding routine services, or diagnosing unnecessary treatment. Waste can also occur when claims are submitted incorrectly due to misunderstanding coding rules or benefit limitations. Regardless of intent, dentists remain responsible for claims submitted under their license and may face fines, license actions, or criminal penalties for violations. [read more]