6 Principles to Prevent your Dental Practice from Unintentional Insurance Fraud

Do you look good in orange  How about black and white stripes? We laugh now, but are you sure that your medical billing for dentistry is compliant with regulations? When it comes to billing medical insurance for dentistry, what you don’t know CAN hurt you! Don’t get complacent with learning and applying the rules to your billing. I am not saying you have to agree with the rules, I sure don’t. Regardless of how you feel, you should want to safeguard your doctor, practice and honestly, yourself.  So, here are some billing principles to make sure you are in compliance:

1. No writing off co-payments or deductibles.

Now, in dentistry, how many times have you heard…we will do your treatment for what insurance pays? That is complete fraud.  
The co-payment is the amount your patient is required to pay per visit. They have a contract with their insurance company and you have to honor it.  When they see their doctor for an office visit, there is a co-payment of 20-25-30 that is their responsibility. This is something you cannot arbitrarily write off.
The annual deductible is the amount your patient is required to meet before the code percentages can be applied. Again, to meet this amount it might not be paid to your practice, but it is a huge benefit for your patient. If your claim is $5,000 and the deductible is $5,000, your claim will be applied to their deductible and is now satisfied for the plan/calendar year. Your practice MUST collect the deductible amount from your patient…it CANNOT be written off.

2. Don’t unbundle codes.

When you take a cone beam image, you bill medical for 70486 using modifier TC for the technical component (only taking the image) or 26 (for only the doctor reading the image). If you take the image and the doctor reads it the same day, you will use no modifier.

Say, for instance, that a practice knows the patient has a pano available on their dental benefits: Instead of billing the D0367, you bill a D0330. You have just unbundled the code.

Don’t let insurance dictate your billing…bill for what you do and do not alter codes because you believe it will be paid. Be honest!

3. Always disclose payment from another insurance.

Whether you bill dental insurance after medical, you MUST disclose what was paid by medical. If your claim to medical insurance was applied to the deductible and you did not receive any payment, then there is nothing to declare because they did not pay. Disclosure of payment from another insurance is vital for compliance.

4. Make sure your documentation supports the claim.

You cannot file a claim with diagnosis codes that are not described in your documentation. Medical insurance does internal audits, and if you were paid by medical and now they want to see your chart notes, you had better have the back up support to prove medical necessity.

5. Never upcode when billing for evaluation and management.

We need to remember that as dental providers who complete medical services, we must stay within the scope of our license (head and neck). What that means for new patients or established patients is that our coding cannot go into examining body systems outside our area (head and neck). Be conservative on your codes for exams because we are looking at two things:

a) Time the doctor spends face to face with the patient regarding only the problem


B) Specific documentation requirements

For instance, if the doctor spends 10 minutes with the established patient but they have an expanded complex health history and expanded doctor exam, you will not be able to bill the larger exam code because the time requirement is 30 minutes.

6. Your fee is your fee is your fee!

That means your dental fee is your medical fee and is also your PPO UCR fee. You cannot charge more than your practice’s usual, reasonable and customary fee because you know medical insurance will pay at a higher rate. This is a big NO-NO.

If your treatment estimate does not match the medical EOB, your dental EOB, and your patient’s ledger, then your patient can contact any of their insurance providers and report a discrepancy. Now, that does not mean that you can’t re-proportion some of your fees in order to maximize medical reimbursement and decrease dental PPO adjustments. Devdent can help you with this.

These 6 principles are a great start, but the best first step to compliance is to attend a Devdent Medical Billing Course for Dentistry or Medical Billing and Dental Sleep Medicine. The education and support are vital to ensure your medical billing success.

Imagn Medical Billing Service

Due to the complex nature of medical insurance billing, most dental offices are not equipped with the knowledge to properly credential national payers, submit successful claims, or handle aging and appeals. Imagn Medical Billing Service performs the proper credentialing and billing for you, which results in fewer denials and time well saved as you rely on expert help.

One-Time Credential Fee

$795/per dentist

The key to more successful payments

Our experts complete the process so you can start billing medical insurance. Each dentist billing medical insurance needs to be credentialed.

Pay Per Case

Verification of Benefit

$35 per vob

We get your patient’s insurance information so you can set proper expectations with the patient regarding the specific coverage available and any out of pocket fees. This is the most critical step in all of medical billing.

Per Authorization

$40 per auth

All procedures require pre-authorization in order for your practice to get paid. Gaining appropriate authorization can be challenging, let our experts get the job done for you.

Claim Submission

8% of successful claim

You don’t have time to sit on hold. Let us sit on hold and handle the claim submission work for you  We also handle the aging and appeals so you can focus on your practice.

Choose Your Software

Imagn Software is your one stop solution with both medical billing and dental sleep medicine capabilities with world-class support

What most dentist don’t know is that medical billing can increase your case acceptance rate and ensure your patients get the care they need.

Imagn Software

$195 /month

No contract and your satisfaction guaranteed.

Our goal is to give you the best experience. But if you are not satisfied then we will give you a full refund for your software access fee within 30 days of purchase.

Add Imagn Sleep Software

$100 /month

Our software provides everything you need

to give your patient’s the sleep care they deserve.

Patients can no longer afford to have dentists ignore the responsibility of providing care for sleep disorders. Two out of every three Americans report poor sleep; the ability to breathe well is the most important factor in determining a person’s sleep quality. 

Imagn Software Set-up Fee

$399 one-time fee

No contract and your satisfaction guaranteed.

Our goal is to give you the best experience. But if you are not satisfied then we will give you a full refund for your software access fee within 30 days of purchase.

Choose Your Monthly Devdent Support Program

In order for you to succeed, we offer a unique range of customer support solutions including coaching, online resources, implementation programming, and so much more. We keep an eye on the ever changing industry trends so you can focus on your practice

Medical Billing Support

$200 /month

The program to get and keep your staff trained.

Dental Sleep Medicine Support

$200 /month

The program to implement Dental Sleep Medicine into your practice.


$345 /month

Get both of the Medical Billing and Dental Sleep Medicine Support programs at a discount.

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