Did You Know That Misrepresenting Treatment is Fraud

When submitting a claim for payment, a dental provider must accurately report to any third-party payer each dental service or procedure that was actually rendered. 

Correctly describing a dental procedure on a claim form may seem fundamental, but it is not always done. Sometimes, porcelain veneers are submitted as full crowns, standard three-month recall visits are submitted as single quadrants of root planing and scaling, and sealants are submitted as single-surface composite restorations. 

Inaccurate submissions may be the result of office error, or confusion over the correct dental procedure code to use. Or, they may be intentional and done for the purposes of obtaining additional benefits. 

The submission of inaccurate or misrepresented dental treatment is one of the unacceptable billing practices reviewed during the claim verification process. The incorrect submission of the dental services or procedures rendered can result in overpayments that are recoverable and lead to other action. If claim forms are intentionally submitted in this fashion, it can be considered a fraudulent attempt to gain benefits. 

For more information, please refer to:

• New Jersey State Board of Dentistry, Administrative Code [NJAC 13:30-8.10] 
• The General Statutes of Connecticut [Volume 7, Title 20, Chapter 379 Sec. 20-114]
• The Delta Dental of New Jersey Participation Agreement
• The Delta Dental of New Jersey Dentist Handbook for Participating Dentists, Chapter 4, Form Completion and Chapter 11, Claim Verifications