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Open Wide: A Dental Insurer Wants Your Money!

By May 11, 2021June 27th, 2023Practice Management

Whether you own a dental practice or associate at one, you expect many of your patients use an oral health care insurance plan to cover at least some of the dental work you provide.

You are used to an insurance company paying for certain hygiene and dental procedures. But you don’t really expect it to go the other way around, do you? What happens when a dental insurer sends you a demand letter telling you that you owe them tens or hundreds of thousands of dollars? Well, the first step is to take a deep breath. And then call a lawyer to get a handle on what you’ve been hit with.

Hopefully you haven’t received such a letter. But there are plenty of dentists who have received such a letter and called us for help. So let me explain where this comes from.

Insurance Company’s View on Billing Fraud

As we know, fraud is a concern in the dental office for many reasons. From an insurer’s point of view, fraud

“typically involves business acts that are inconsistent with identified acceptable and legitimate financial practices and can result in additional and unnecessary costs to the insurance carrier, the group, the broker, or to the insured”. 1

The main acts that have an insurance company seeking reimbursement and damages from dentists are:

  • performing services not clinically necessary or justified
  • waiving copayment or deductible
    • This results in a change in fees charged by the dentist, inconsistent with what the insurance carrier believes is being charged.
  • allowing unlicensed personnel to perform procedures (assistants, hygienists, etc.)
  • unbundling claims
    • Submitting several procedures separately to receive higher reimbursement.
  • billing for services not performed or not completed
  • altering records or claims to enhance billing
  • misrepresenting the services performed
    • For example, performing a cosmetic service but billing for a covered service.
  • revising the dates of the services performed
  • upcoding dental procedures
    • Submitting a claim for a procedure that is more complex than the one performed.

The acts listed above are a primary concern for insurance companies because “the insured may suffer from a lack of needed care, incorrect care, or deficient care” 2 which could result in additional unnecessary costs to the insurer.

Moreover, the insurance company does not want to be deceived into paying more than it should. And that is where the risk to the dentist to pay tens or hundreds of thousands of dollars resides.

Billing Fraud Allegations in the Dental Office

Here is the usual way we have seen such a situation play out.

An insurance company conducts verifications (aka audits) on claims your dental practice submitted to them on behalf of your patients, who have dental coverage through a Group Benefits plan. If the insurer suspects something may not be quite right from the audit, the company will send you a letter asking for specifics on one or more claims. If their review of your answers reveals an irregularity, you receive a follow-up letter from the insurer alleging your office has – in contrast to their statistics from ‘data mining’ claims submitted to them by other dental offices – over-billed as a result of using incorrect codes or unjustifiably billing the maximum amounts for a treatment.

Classic allegations of incorrect coding or over-billing (whether intentional or not) include:

  • using the specific (01204) or emergency (01205) examination codes for what was scheduled as a recall examination;
  • billing one full unit for polishing (e.g. 11101) at the maximum time/fee for the service where limited polishing is the clinical norm;
  • using a complete examination code (e.g. 01101, 01102 or 01103) automatically after a set period for a patient you see regularly;
  • submitting claims which don’t correctly differentiate scaling (e.g. 11111, 11117 and 11119) from root planing (e.g. 43421 to 43427 and 434249);
  • including code 49101 with root planing and/or scaling;
  • claiming the maximum amount of time for some procedures, such as desensitization (41301); and
  • submitting claims for orthodontic band splints (43261) in place of orthodontic codes 83201 or 83202.

Included with the allegation will be some examples of patient claim submissions and a calculation to show what they believe you have over-billed. But then, the insurance company will also allege that if you incorrectly coded or irregularly maximized billing on these specific patients, then you must have done the same on all your patients. And not only for the period they audited but for several more years!!!. And it is from that extrapolation that the insurance company claims you owe them hundreds of thousands of dollars.

Bottom Line for Your Practice

At the end of the day, when you are busy providing top-notch oral health care all day, the last thing you want or need to deal with is an insurance company audit. Further, audits can hurt you financially because you will need legal assistance to refute the insurance company’s allegations. You may also have to repay some monies to the insurance company. Compounding matters is the risk that your billing practices are reported to the RCDSO as fraudulent. And then, any results of an RCDSO investigation would be noted on the RCDSO’s website. This is the kind of publicity that is never good for your business or your reputation.

If you ever receive a demand letter from an insurance company alleging the use of or unjustifiable billing practices, call us. We can help you before you say or do the wrong thing and potentially make matters worse.



1, 2: Sun Life Assurance Company of Canada

The Content of this post is provided for informational purposes only. It is not intended to be legal, financial, tax, or other professional advice of any kind. You are advised to contact DMC (or other counsel) to seek specific legal advice concerning your individual situation.