In 2017, the Department of Justice recovered over $2 BILLION dollars of fraud in the health care industry.  Whistleblowers who reported the fraud are the government’s main weapon in the recovering the defrauded funds.  The False Claims Act incentivizes whistleblowers by allowing a whistleblower to receive a percent of any recover.

Fraud can be found in all areas of the health care industry, including the dental industry.  Dental fraud that targets the Medicare and/or Medicaid programs implicates the federal and some state False Claims Acts. Some states that have false claim acts are North Carolina, Virginia, Tennessee, Georgia, Maryland, as well as the District of Columbia.   Here are seven common examples of dental fraud.

  1. Billing for services not performed.

Billing for a service that was not performed is plain and simple fraud.  However, billing for a completed service that was partially perform may also be considered fraud.  For example, billing for a crown when prep was only performed may be considered billing for services not performed.

2. Upcoding

Codes are used to represent a level of medical difficulty that reflect a corresponding reimbursement.  Upcoding is using a code that represents a more extensive degree of difficulty to achieve a higher reimbursement rate.  For example, billing for a periodontal scaling and root planning instead of a standard proophylaxis.

3. Waiver of co-payment and deductibles.

Medicare and Medicaid both require co-payments and deductibles. Waiving co-payments and/or deductibles to encourage additional procedures or treatment, thereby resulting in additional charges and reimbursements is considered fraud.

  1. Changing dates of service.

Changing dates of service to allow a patient to receive Medicare and/or Medicaid when otherwise ineligible is considered fraud.

  1. Unbundling

Using several codes to bill for a service when once code is appropriate is considered fraud.

  1. Substituting patient identities.

Performing a service on one person but billing in the name of a different patient is fraud.

  1. Not disclosing primary coverage.

This often happens when a provider bills two insurance companies for the same service, and does not disclosing the existence of the other insurance policy.

The government realizes that most fraud goes unreported and most people who are aware of fraud against the government are inside employees. To encourage whistleblower to report fraud, the False Claims Act allows a whistleblower to receive a percentage of any recovery.  The FCA also provides whistleblower protection against workplace retaliations by the employer.

Retaliation can include, firing, reduction in pay, suspensions, reduction in hours, harassment and threats.  If retaliated against, whistleblowers may receive up to two times back pay, special monetary damages, and legal fees.

If you suspect dental fraud, or other health care fraud, contact Miller Law Group for a free consultation, or call 919-348-4361.