dental billing practices

Illegal Dental Billing Practices You Should Avoid

Dental billing is a crucial part of revenue cycle management for dental practices. More than 50% of US adults have dental insurance, and about two-thirds of dental practices participate. Missed dental billing processes can lead to significant revenue loss, with the typical dental business losing 9% of recoverable income annually. Upholding high standards and ethical principles is essential to maintaining the trust and ensuring success in this field. Fine-tuning RCM practices are crucial during times of economic instability. By optimizing RCM practices, dental practices can improve payment collection and minimize revenue loss.

Overview Of Illegal Dental Billing 

Fraudulent billing and claims practices are prevalent in the dental industry. Engaging in illegal dental billing practices can have severe consequences. Providers may face legal and financial penalties for fraudulent billing activities, including fines, imprisonment, and license revocation. In addition to legal matters, providers may damage their professional reputation and lose patient trust. Dental practices may also face financial losses and decreased revenue due to fraudulent billing activities. Maintaining transparent and ethical billing practices is crucial to protect both the provider and the patient.

Illegal dental billing practices refer to unethical or fraudulent activities related to dental billing, coding, and insurance claims. Achieving long-term success involves timely payments from insurance carriers and accurate claims submissions. Effective dental billing can improve payment collection and optimize the revenue stream for dental practices. Medical billers and coders are responsible for upholding ethical and professional standards at work. This is especially true when dealing with sensitive information and financial matters related to providers, payers, and patients. Medical billers directly impact the economic well-being of those they serve. Medical billers must prioritize accuracy, confidentiality, and ethical behaviour in their work, with their critical role in the healthcare industry.

Common Illegal Dental Billing Mistakes To Avoid

There are many common illegal mistakes that harm the dental RCM and patient satisfaction. Some of the following is essential to avoid dental billing mistakes. 


Upcoding is a significant fraudulent activity that must be avoided. It involves billing for more expensive services than the ones provided. This can be done by using codes for services that the patient did not receive or for more intensive procedures than what the provider performed. The ADA defines upcoding as reporting a more complex and higher-cost process than was performed. Insurance companies and regulatory agencies closely scrutinize upcoding to avoid insurance rule evasion and overbilling. Therefore, dentists need to bill only for the services provided.


The act of unbundling in dental billing involves breaking down a procedure into its components, with each part having a charge, resulting in a higher cumulative charge. The American Dental Association (ADA) defines unbundling as separating a dental procedure into its parts to increase reimbursement. This can occur due to an unintentional error or intentionally to maximize reimbursement. Practices should have a good understanding of payer rules regarding bundled services to avoid this fraudulent billing practice. It is essential to use only the necessary CDT codes to reflect patient services accurately.

Billing for services not rendered

Among these practices, billing for services not performed or completed is the most common. Ensuring that all services claimed were performed or completed as reported is crucial. Providers must avoid inflating claims by upgrading the level of service or reporting a routine cleaning which commands a higher fee. It is essential to maintain accurate and transparent documentation of all services rendered.

Altering the dates of service

Another fraudulent billing practice is altering the dates of service on a claim. This happens when a claim is submitted with an incorrect service date, such as billing for a crown on the preparation date instead of the seat/cementation date. Although this may seem insignificant, the service date can impact patient coverage, mainly if the treatment occurred before their plan’s effective date or waiting period. To maintain ethical billing practices, providers must ensure that claims are submitted with accurate and appropriate dates of service to avoid any potential legal or financial consequences.

Use of additional codes

Dental providers must avoid improper use of additional codes when submitting claims for treatment. Selecting the most appropriate code that accurately describes the service is essential. Providers should refrain from separating each step of a procedure into individual codes, a practice called unbundling, which is strictly prohibited. For example, instead of billing for local anesthesia, incisions, drainage, and sutures separately for an extraction, bill only for the extraction procedure. Proper use of codes in billing and claims submissions is crucial for ethical and transparent billing practices.

Waiving deductibles or copayments

Some Delta Dental plans offer deductible or maximum waivers for diagnostic and preventive services, but not all programs have this benefit. Additionally, some plans may require patient coinsurance even for in-network D&P services. Waiving these payments is considered fraudulent because the fee billed on the claim does not match the amount intended to be collected. Dental providers should avoid waiving these payments and instead consider offering payment plans or denying care if patients insist on the waiver. Proper billing practices ensure transparent and ethical financial transactions.

Submitting a claim using a different member’s information

Ensuring that you’re submitting claims for the correct patient is essential. Intentionally submitting a claim under another patient’s name to have the procedure covered is fraudulent. The procedure date is tied to the patient’s medical eligibility and waiting periods. Always confirm the patient’s information before submitting the claim.

Prevention Of Illegal Dental Billing 

It is important to manage revenue by preventing illegal dental billing practices actively. This entails knowing the various activities taking place within your practice. Here are some ways to avoid dental billing fraud.

Code Of Conduct 

Establishing a code of conduct that includes a fraud policy can help reduce the risk of dental billing fraud. Educating your billing staff about the advantages of submitting truthful claims and the consequences of submitting fraudulent claims is crucial. Implementing a policy that enables your staff to report any suspicious activities is essential. Proper training can ensure that your team is familiar with the latest billing codes and regulations. They should also understand the consequences of fraudulent billing, including legal and ethical violations that can harm the patient and the practice’s reputation. 

Maintain Updated and Proper Documentation

It’s essential to maintain accurate and up-to-date documentation. This ensures that all information in the billing statement is correct and benefits medical practitioners in providing the best possible treatment and services. Moreover, this documentation is integral to the patient’s medical record, so its accuracy is crucial for protecting the patient. Inaccurate information can compromise the patient’s health and affect the quality and accuracy of future care. Therefore, maintaining proper documentation is essential to avoid the irresponsible and reckless practice of risking patient health due to inaccurate billing.

Conduct Regular Audit 

Conducting regular audits is essential to avoid penalties and maintain the integrity of your business. Regular auditing has several benefits, such as faster identifying bottlenecks, problems, risks, or errors in a process or quality management system. It enables you to implement improvements based on these new insights more efficiently and receive better feedback on the effect of any measures taken. Additionally, audits help demonstrate compliance with industry-specific standards and legal requirements, which can improve your company’s image, and reputation by avoiding or reducing fines. Keeping your staff informed and up-to-date can minimize the risk of accidental or intentional fraudulent billing, saving you time, money, and legal trouble in the long run.

Follow Compliance Policies

Implementing and following compliance policies and procedures are essential to avoid illegal dental billing practices and ensure a smooth dental revenue cycle management (RCM) process. As part of this process, it’s necessary to establish a comprehensive compliance program that includes regular training for staff on the latest regulations and coding guidelines specific to dental RCM. This program should also outline precise procedures for documentation, billing, and claim submission and how to handle any suspected fraudulent activity. 

Use a Dental Billing Software 

Dental revenue cycle management (RCM) software can help streamline and automate many administrative tasks. It is associated with billing and claim submission and reduces the risk of errors and fraudulent activity. These software solutions provide real-time data and analytics to help you identify any issues in the billing process. By using dental RCM software, you can ensure accurate documentation, reduce claim rejections, and speed up reimbursement times. It can ultimately improve your practice’s revenue and profitability. 

Hire A Dental Billing Expert 

Investing in a dental billing service that has been professionally trained to avoid illegal dental billing practices is essential. It’s crucial to ensure that everyone on your team is aware of and compliant with any upcoming coding or insurance regulatory changes. Delays and denials of insurance claims can lead to decreased revenue, so outsourcing your insurance verification and billing tasks can boost your profitability. Dental billing outsourcing focuses on collecting insurance payments promptly and increasing cash flow in real time. They also check for overdue accounts and work to trace, fix, and invoice any problems or complaints. Choosing a reputable and reliable dental billing service provider with expertise and experience is essential to help your practice succeed.


Engaging in fraudulent activities in the dental industry has negative consequences for everyone involved. Furthermore, dental practices that are found to be engaged in fraudulent activities may face severe penalties such as fines, loss of network participation, revocation of professional licenses, and even imprisonment. By taking proactive measures to maintain ethical billing practices, dental practices can build trust with their patients and establish themselves as reliable and trustworthy healthcare providers.

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