The following list of Do’s and Don’ts are simple ways you can help prevent providers from committing insurance fraud, and prevent you from avoid becoming a victim. Be sure to contact the appropriate authorities if you think you are a victim or witness to insurance fraud of any type.
Dental Office Awareness
Delta Dental considered all of the following as unacceptable billing practices in the dental office:
Delta Dental participating dentists may not submit any claims to Delta Dental for services performed by dentists who are not participating dentists with Delta Dental on the date(s) when the services were performed.
To receive direct payment as a participating dentist, every dentist in a dental practice must sign a participating dentist agreement and credential with Delta Dental as a participating dentist.
Usual Fee - Participating dentists must file their “usual” fees as defined in the Bylaws of Delta Dental of New Jersey, Inc. “Usual” fee is the fee that the dentist most frequently actually charges to and collects from his/her uninsured patients as payment in full, less any discount which is regularly offered to patients, other than a discount which reasonably reflects the time value of money.
Uninsured means without dental coverage, but exclusive of patients covered by governmental assistance programs such as Medicaid.
Patient discounts are permitted as long as the discount or any waiver of co-payment responsibility is noted on the claim form.When extending a discount, it should be applied to the fee for the service rendered so that the net fee submitted to Delta Dental and the net fee charged to the patient are both reduced.(Discounted fees must be specified on claims submitted for payment).