Dental payers face consistent challenges as fraud, waste, and abuse (FWA) continue to escalate costs and threaten the integrity of the system. In 2023, dental expenditures in the United States reached $174 billion, accounting for over 3% of total healthcare spending, according to the American Dental Association. As dental claims continue to grow in both volume and complexity, plans face difficulty identifying improper billing practices amidst the evolving landscape of FWA schemes. Understanding and addressing current dental claim schemes is critical to ensure a fair and transparent environment for payers and providers while protecting member benefits.
Abused codes and claim splitting are two common examples of FWA detected in dental claims. Some of the most frequently misused codes involve bone grafts, buildups, non-surgical root canal obstructions, antimicrobial agents, and surgical extractions. In 2024, Cotiviti Dental Claim Accuracy clients were billed $14.7 million for bone grafts, where clinical review identified and prevented $3 million in improper payments from unnecessary add-ons. Buildups under crowns accounted for over $52 million in charges, uncovering $8.4 million in improper billing with expert review, and leading to significant savings.
Claim splitting is a common practice that can be useful for administrative purposes, but it can also be misused to maximize reimbursements. Providers might divide what should be one claim—such as multiple extractions or combined procedures like X-rays and root canals—into separate submissions to manipulate outcomes or disguise the actual services provided. These practices can fuel higher costs, complicate the claims process, and provoke unnecessary investigations.
To address these issues, dental payers can implement strategies like conducting comprehensive utilization reviews to identify patterns of code abuse and claim splitting, and enforce strict documentation requirements to ensure proper justification for billed procedures. Through these concerted efforts, the dental industry can protect payment integrity, contain costs, and uphold ethical practices.
For a deeper dive into claim splitting trends and key recommendations, read our eBook, Navigating dental claim FWA: The impact of abused codes and claim splitting. Check out our expert resources to combat common dental payment FWA and stay informed about how Dental Claim Accuracy can benefit your organization.
Headed to the 2025 NADP Converge Conference from September 15–18? Stop by the Cotiviti booth (#303) to play our "Expert Eye" game and we'll thank you with a free on-the-go travel kit. Learn more about how our prepay Dental Claim Accuracy solution performs beyond expectations to catch errors, reduce the costs of postpay audit and recovery, and improve compliance.