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Dental fraud and the hygienist’s role

June 1, 2019

Picture yourself temping in an office, and you overhear the front office team tell a patient, “Yes, there’s a temp hygienist treating patients today. You aren’t due for a cleaning until next week.” She’s holding the insurance claim so that the patient will receive her benefit rather than having the patient pay that day. You also notice that a crown was billed on the date it was prepped, not on the day that it was seated. Does either of these situations constitute fraud? The answer is yes! But the answer also depends on a number of factors. I will review examples of dental fraud and the hygienist’s role.

      What is fraud?

      According to Dictionary.com, fraud is deceit, trickery, or breach of confidence perpetrated for profit or to gain some unfair or dishonest advantage. In dentistry, dental fraud is any act of intentional deception or misrepresentation of treatment facts made for the purpose of gaining unauthorized benefits. Acts of dental fraud contain three defining features: intent, deception, and unlawful gain.1

      Some examples of dental fraud include misrepresentation of dates of service, waiving of deductibles or copayments without notifying the benefit provider, billing for services not provided, or diagnosing unnecessary treatment. Hygienists are not often responsible for coding and billing patients, yet depending on a variety of state or federal rules and regulations, they can be held liable for acts the practice commits. Therefore, it is essential for hygienists to understand the implications of billing and coding since ignorance is not a defense in any criminal or civil matter.

      Since what constitutes dental fraud varies depending on a state’s practice act and insurance commission’s regulations, this article will encourage hygienists to learn more about fraud in their states and practices. Here are some examples of dental fraud.

      Misrepresenting dates of service

      When a claim is submitted to a dental benefit provider, it is fraudulent to use any date other than the date on which treatment was rendered. The date of treatment is related to patient eligibility and waiting period requirements of the benefit provider, and it needs to match appointment scheduling and clinical notations. The clinical notes are the legal document for treatment and if the dates of treatment submitted don’t match the clinical notations, this can be fraud. Even if no dental benefit is involved, there needs to be consistency between scheduling, billing, and notes.

      According to the American Dental Hygienists’ Association 2016 Standards for Clinical Dental Hygiene Practice, “Hygienists must recognize ethical and legal responsibilities of recordkeeping, including guidelines outlined in state regulations and statutes.”2 If a claim is submitted that has information that is not consistent with clinical notes, that’s a red flag. Hygienists need to understand the implications of appropriate billing and documenting information.

      When a patient receives a discount on treatment and the practice participates in a dental benefit plan, the dental practice should inform the benefit provider of the reduced fee. The appropriate area to note such information is the narrative section of the claim form. The benefit provider has the authority to process either the full amount of the claim or a reduced rate. If a practice has a specific benefit provider, the contract signed by the practice is the binding agreement for notifying the benefit plan regarding discounts. Specific state insurance regulations also dictate information regarding discounts of copayments or fees.

      Billing for inaccurate or unnecessary treatment

      During recent years there have been a number of cases of dental practices being sued by state attorneys general over Medicaid abuse and fraud that were the result of inaccurate or unnecessary treatments. These range from excessive fluoride treatments to undocumented exams to safety pins placed as root canal therapy!

      Even private pay benefit providers are examining claim forms for fraud abuse. Delta Dental recently fined a practice that submitted for oral evaluations during hygiene visits when a doctor was not present. The practice had to pay a fine and reimburse Delta the amount of the exams. Although the hygienists in the practice were not held liable, the practice suffered in a variety of ways.

      With the increasing scrutiny cases such as these have generated, dental benefits providers are increasing their focus and examining claims for possible fraud. Red flags such as a higher-than-average use of a particular code or excessively high fees when compared to other area providers may be indications to benefit providers that there may be fraud.

      As licensed dental professionals, hygienists need to provide codes for their work. Our role is to use the most accurate code to describe the procedure performed. Treatment should be based on clinical need, not on covered services. Changing a code for the purpose of increasing payment by using either a higher or lower level code can be considered fraud, for example, using D1110 instead of D4346.

      Fraud by accident or ignorance

      Fraud by accident or ignorance is still fraud.3 Hygienists are often asked to alternate prophy and periodontal codes for the purposes of obtaining coverage. There are flow charts that help make these complex choices easier to follow. Most periodontal disease flow charts make little mention of gingival disease, and most flow charts do not include coding for implant care. On June 21, 2018, the American
      Academy of Periodontology (AAP) published the Classification of Periodontal and Peri-Implant Diseases and
      Conditions 2017
      . These updates include a staging and grading system for health, gingival disease, periodontitis, and classifications of peri-implant disease.4 With this new staging and grading system, hygienists can now explain their reasons for not alternating codes.

      Where to turn

      If you’re aware of fraud in a practice, most dental benefit providers offer an anonymous tip line. States also offer fraud abuse hotlines that may or may not be anonymous. The organization Coalition Against Insurance Fraud (insurancefraud.org) discusses dental insurance fraud (insurancefraud.org/scam-alerts-dental.htm). No matter what its form, fraud costs individuals, benefit providers, and practices in numerous ways. The case of Roy
      Shelburne, DDS, illustrates how fraud can cost individuals, practices, and patients.5 Hygienists can hold the keys to educating practices and patients about the consequences of dental fraud.


      1. Lewis DP, Farragher GP. Dental health-care fraud and abuse. Dental Economics website. https://www.dentaleconomics.com/articles/print/volume-103/issue-12/features/dental-health-care-fraud-and-abuse.html. Published December 19, 2013.
      2. Standards for Clinical Dental Hygiene Practice. American Dental Hygienists’ Association website. https://www.adha.org/resources-docs/2016-Revised-Standards-for-Clinical-Dental-Hygiene-Practice.pdf. Revised June 2016.
      3. DiGangi P. Dental fraud by accident or ignorance at RDH Under One Roof. https://www.dentistryiq.com/articles/2018/07/fraud-by-accident-or-ignorance-at-rdh-under-one-roof.html. Published July 17, 2018.
      4. American Academy of Periodontology releases proceedings from the 2017 World Workshop on the classification of periodontal and peri-implant diseases and conditions. American Academy of Periodontology website. https://www.perio.org/node/876. Published June 21, 2018.
      5. Anderson P. One year out of prison, Dr. Roy Shelburne has a message. DentistryIQ website. https://www.dentistryiq.com/articles/2010/05/out-of-prison-dr-roy-shelburne-has-a-message.html. Published May 24, 2010. Accessed May 1, 2019.

      Ann-Marie DePalma, MEd, RDH, CDA, FAADH, FADIA, is a technology advisor for Patterson Dental, a writer for RDH magazine, and an author in dental hygiene textbooks. She is the 2017 MCPHS Esther Wilkins Distinguished Alumni recipient. She is a fellow of the Association of Dental Implant Auxiliaries and American Academy of Dental Hygiene, a continuous member of the American Dental Hygienists’ Association, and an active member of the Massachusetts Dental Hygiene Association.