As healthcare costs rise, dental costs have been no exception\u2014recently increasing by $4 billion in a single year<\/a>. With national dental expenditures reaching $174 billion in 2023, representing more than 3.5% of all healthcare expenditures, it\u2019s no surprise that dental procedures continue to be a ripe target for fraud, waste, and abuse (FWA) through schemes such as unnecessary or excessive procedures, up-coding, and duplicate billing. In fact, the\u00a0National Health Care Anti-Fraud Association (NHCAA)\u00a0estimates that 3-10% of healthcare payments in the United States are lost annually due to fraud, waste, and abuse (FWA).<\/p>\n While most dental practitioners strive to comply with dental plan billing policies and provide the best possible care for their patients, when inappropriate billing does occur, it erodes trust in both dental providers and plans alike\u2014while also wasting the member\u2019s valuable plan benefits and driving up costs for everyone.<\/p>\n Recently, Cotiviti\u2019s own special investigations unit (SIU) identified one dental provider through proactive data analysis for potentially excessive billing of Current Dental Terminology (CDT) codes D2140 <\/strong>through D2394, <\/strong>which cover restoration procedures such as fillings and crowns. Our SIU submitted its initial findings to the dental plan, which agreed that further review was warranted. Investigators then used Cotiviti\u2019s advanced FWA software solutions to pull and analyze the last two years of claims data for suspect billing patterns, which identified that these restoration procedures accounted for 25\u201330% of all payments made to the provider\u2014significantly higher than the provider\u2019s peers.<\/p>\n Additional research revealed the provider was billing at multiple locations on the same dates of service, resulting in potential \u201cimpossible days\u201d\u2014a scenario in which it would be physically impossible for the provider to perform the amount of services billed within a 24-hour period.<\/p>\n Our SIU\u2019s internal review of the provider\u2019s documentation confirmed a 100% error rate for CDT codes D2140 through D2394, including:<\/p>\n Ultimately, Cotiviti\u2019s investigators found that 93% of patients being treated did not have documented informed consent, either obtained verbally or signed. The overall identified overpayment for the plan exceeded $33,000.<\/p>\n After the dental plan informed the provider of Cotiviti\u2019s findings, the provider\u2019s office conducted an analysis of its internal claim systems. This resulted in the provider learning that their internal systems were set up incorrectly and automatically applying the owner\u2019s National Provider Identifier (NPI) on all claims. The dental plan then set the provider up on a corrective action plan to be followed.<\/p>\n To mitigate future FWA scenarios and avoid the often costly, burdensome process of recovering overpayments, dental payers should consider the following best practices:<\/p>\n As this example shows, using automated solutions and professional review of dental claims, dental payers can combat inappropriate billing practices while protecting their members and educating providers. Read our white paper by Cotiviti\u2019s Steven M. Canfield, D.D.S.<\/strong> as we:<\/p>\nThe view from our SIU: Identifying the excessive billing<\/h2>\n
Reviewing the documentation<\/h2>\n
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Key takeaways for dental payers<\/h2>\n
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Counteracting FWA in dental payments<\/h3>\n
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