“If we notice a pattern of abuse by one provider, we may look at the whole provider community.”
Julie R. Ferrini, RDH,
Director of Program Integrity and Dental Case Management.
We’re all familiar with stories of Medicare and Medicaid fraud in the health care industry, but did you know that billions of dollars are wasted on dental care fraud every year? According to the National Health Care Anti-Fraud Association (NHCAA), of the $250 billion spent on dental care procedures annually, an estimated $12.5 billion - or 5% - is lost to dental fraud and abuse. As your dental plan administrator, Altus Dental adds value through our proactive efforts to monitor and investigate all cases of suspected fraud.
Fighting dental fraud is an essential part of how we conduct our business – from training and education of our internal staff to a dedicated anti-fraud program that stands out among other local dental carriers. Our ongoing, professional review of high dollar claims also serves to detect patterns of abuse.
Over the years, Altus Dental’s anti-fraud program has investigated cases ranging from:
What’s the difference between Fraud and Abuse?
Fraud is considered the intentional deception or misrepresentation of information. It is usually committed to gain payment or insurance benefits from another entity, which is then harmed as a result.
Abuse occurs when dentists practice in a manner that is inconsistent with accepted treatment standards, again resulting in unnecessary costs and harm to the patient.
Why it Matters
Fraud inflates the cost of private and government dental plans, and everyone pays the price. Employers pay through increased premiums, and members pay through higher co-payments and deductibles. The end result can be reduced dental benefits and even the elimination of dental coverage altogether.
Types of Fraud and Abuse
Here are some examples of the different types of dental fraud and abuse:
Perhaps the most common type of fraud occurs when a patient and dental office act in collusion to submit a claim that has an incorrect date or type of service other than what was delivered, in an attempt to have non-covered services paid by the insurance company. Altus Dental’s contracts with our network dentists prohibit this type of fraudulent activity.
What is Altus Dental doing to Fight Fraud?
Altus Dental’s multi-pronged efforts start with sophisticated dental software with built-in checks to detect any anomalies. The automated system will suspend duplicate claim submissions, or flag claims that are continually being resubmitted with a new code for monetary gain.
Even with the best systems, however, there is no substitute for human interaction. A fraud case can often begin with a simple complaint. Our Customer Service staff is the first line of defense in detecting fraud and abuse cases. Our representatives are trained to listen intently and forward any complaint of a suspicious nature to our Quality Assurance Coordinator for further investigation. The coordinator will interview all involved parties, including the member, any treating dentists and/or dental office staff. If the case is not resolved during this process, we will then audit the practice, requesting documentation such as treatment notes, x-rays, photographs and medical history. During the audit, we may flag all claims from a particular dentist’s office for further review.
An estimated 30% of all complaints require further investigation. One in 10 will result in a full office audit. If the audit proves that fraud has occurred, possible sanctions against the dentist include: probation or suspension from our dental network, re-auditing of the practice and regulatory and legal sanctions. Altus Dental also works closely with state and federal regulatory and law enforcement agencies, if warranted.
Education is the Key to Prevention
Altus Dental conducts company-wide training in front-line areas like sales, customer service and operations. “As an organization, we believe in annual training to alert all employees who are in a position to learn of suspicious activity,” said Ferrini. We also work with dental offices to review proper record-keeping procedures as well as to help them to understand our processing policies and guidelines. To raise awareness of potential fraud among our members, we include anti-fraud messages on our Explanation of Benefits (EOBs). You can help by letting your employees know that dental care fraud is a serious crime.
What You Can Do
Consumers and businesses can help in the fight against fraud because it ultimately hurts all of us financially. As a Plan Administrator, you can help us prevent fraud in the following ways: