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Preventing Insurance Fraud


Take the right steps early to prevent your practice from becoming involved in insurance fraud. The penalties are great. Not only could you could be fined, but you could also lose your practice or even be put in jail. It is critically important to know what fraud is and how to prevent it in order to protect your reputation and your livelihood.

It’s More Common Than You Think

Insurance fraud does not just affect one practice or one patient. The results are much farther reaching. Insurance fraud is one of the main causes of high insurance costs. If there is abuse of the system, it is a no win situation for everyone involved. Insurance companies lose money and patients often end up paying higher insurance costs as a result.

As a result of the large amount of healthcare fraud that exists in the United States, Congress enacted the Health Insurance Portability and Accountability Act (HIPAA) in 1996. This law makes healthcare fraud a federal offense with serious penalties.

According to the US Department of Health & Human Services the law also changes the way health care providers have to protect the privacy of patient’s health information and contains security procedures that must be followed to protect the integrity of a patient’s health information. As a private practice owner you are responsible for fully understanding and with providing your patients with information regarding this act.

Protect Yourself and Your Business

How does a private practice owner prevent insurance fraud? Let’s determine what constitutes insurance fraud, first. The American Dental Association defines dental insurance fraud as any crime where an individual receives insurance money for filing a false claim, inflating a claim or billing for services not rendered.  Acts of dental fraud contain three defining features: intent, deception, and unlawful gain.

What are a few examples that you might see in your office, which constitute themselves as fraud?

  • Billing for a service that was not performed (such as an exam during a patient recall, if the doctor did not actually come in to see the patient.)
  • Miscoding (filing a porcelain veneer as a crown.)
  • When making a referral while receiving payment or other benefit known as "kickbacks"
  • Excessive or inappropriate testing
  • Not returning overpayments
  • Referring patients to specialists when it is not clinically necessary
  • Scheduling follow up visits that are not needed

Unfortunately, most dentists do not have any formal training in business management and therefore need to arm themselves with the proper knowledge to protect their business and their employees. Getting started can be fast and cost-effective. Here are few simple steps to follow:

  • Know your employees. Be aware and more focused if you have an employee facing family or financial problems.
  • Always perform background checks on all employees prior to hire.
  • Stay up to date on new technology and computer applications that can help monitor your business accounts and transactions.
  • Utilize the reporting programs in your management systems to help find alerts and trends in your business.
  • In the event you suspect fraud seek the advice and counsel of lawyers and certified public accountants in order to obtain a more detailed investigation.

** The best prevention is education. As the business owner it is your responsibility and obligation to be informed about what fraud is and to ensure that all staff is held accountable for billing and processing claims properly.

Business - Medical and Dental Industry

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This article contains general information only. Sunflower Bank is not, by means of this article, rendering accounting, financial, investment, legal, tax, or other professional advice or services. This article is not a substitute for such professional advice or services, before making any decisions related to these matters, you should consult a qualified professional advisor.