Dental fraud and abuse

What is dental fraud and abuse?

• Fraud is any act of intentional deception or misrepresentation of fact made for the purpose or likelihood of gaining an unauthorized benefit. Acts of dental fraud involve three defining features: intent, deception, and unlawful gain.
• Fraud can originate from a number of sources: providers and/or consumers of care.
• Fraud and abuse, involving providers, typically involves business acts that are inconsistent with identified acceptable and legitimate financial practices and can result in additional and unnecessary costs to the insurance carrier, the group, the broker, or to the insured. It is also possible that the insured may suffer from a lack of needed care, incorrect care, or deficient care as a result.

What does an act of dental fraud look like?

• Performing services not clinically necessary or justified
• Waiver of copayment or deductible - results in a change in fees charged by the dentist, inconsistent with what the insurance carrier believes is being charged
• Unlicensed personnel performing procedures (assistants, hygienists, etc)
• Unbundling of claims - submitting several procedures separately to receive higher reimbursement
• Billing for services not performed or not completed
• Altering records or claims for the purpose of enhancing billing
• Misrepresentation of services (performing a cosmetic service but billing for a covered service)
• Misrepresentation of dates of service
• Upcoding of dental procedures - submitting a claim for a procedure that is more complex than the one actually performed

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What are we doing about dental fraud and abuse?

We have developed a program designed to significantly raise the awareness of our members, employers, brokers and network providers concerning dental fraud.

• We focus on the ability to detect possible acts of dental fraud through several departments: our claims department, as well as the Quality Improvement department as a part of our credentialing and peer review process, and our grievance review and resolution process.
• We openly communicate our program and its intent to our networks through website communications, mailings and communications through our recruiters.
• Our goal is more than detecting fraud when it occurs. Our first priority is to prevent fraud whenever we can by deterring any person who may indiscriminately consider committing such an act.
• Building a program of prevention of new acts of fraud and one that addresses acts that are committed, is an ongoing, long-term effort.

We are currently confronting suspected acts of fraud through our grievance resolution process. We take corrective action to prevent repeat violations and to protect our members. This is an important feature for our company.

What do I do if I suspect or become aware of an example of dental fraud or abuse?

We have an electronic mailbox to which either grievances or matters of suspected dental fraud and abuse can be forwarded. Upon receiving this information, we will evaluate the matter to determine if any errors, acts of potential fraud or communication mistakes have occurred. We contact the dentist concerning the matter and attempt to address and resolve the concern as quickly as possible.

Please email us at slfgriev@sunlife.com.