FWA Insights: Excessive dental restorations

As healthcare costs rise, dental costs have been no exception—recently increasing by $4 billion in a single year. With national dental expenditures reaching $174 billion in 2023, representing more than 3.5% of all healthcare expenditures, it’s no surprise that dental procedures continue to be a ripe target for fraud, waste, and abuse (FWA) through schemes such as unnecessary or excessive procedures, up-coding, and duplicate billing. In fact, the National Health Care Anti-Fraud Association (NHCAA) estimates that 3-10% of healthcare payments in the United States are lost annually due to fraud, waste, and abuse (FWA).

While most dental practitioners strive to comply with dental plan billing policies and provide the best possible care for their patients, when inappropriate billing does occur, it erodes trust in both dental providers and plans alike—while also wasting the member’s valuable plan benefits and driving up costs for everyone.

The view from our SIU: Identifying the excessive billing

Recently, Cotiviti’s own special investigations unit (SIU) identified one dental provider through proactive data analysis for potentially excessive billing of Current Dental Terminology (CDT) codes D2140 through D2394, which cover restoration procedures such as fillings and crowns. Our SIU submitted its initial findings to the dental plan, which agreed that further review was warranted. Investigators then used Cotiviti’s advanced FWA software solutions to pull and analyze the last two years of claims data for suspect billing patterns, which identified that these restoration procedures accounted for 25–30% of all payments made to the provider—significantly higher than the provider’s peers.

Additional research revealed the provider was billing at multiple locations on the same dates of service, resulting in potential “impossible days”—a scenario in which it would be physically impossible for the provider to perform the amount of services billed within a 24-hour period.

Reviewing the documentation

Our SIU’s internal review of the provider’s documentation confirmed a 100% error rate for CDT codes D2140 through D2394, including:

• The provider indicated as having performed the services was not the billing provider noted on the claim line, indicating potential pass-through billing, a common scheme that occurs when a provider pays another provider or entity to perform a service, yet bills the payer as though they performed the service themselves—a potential violation of federal fraud and abuse laws. In this case, services were performed by associates who were not properly credentialed.
• The clinical note for patients did not document decay, and no x-rays were submitted to show proof of decay.
• The codes were incorrectly reported. The documentation showed that a different level of restoration was completed than was billed.
• The clinical notes did not contain a valid signature, and therefore the rendering provider could not be verified.

Ultimately, Cotiviti’s investigators found that 93% of patients being treated did not have documented informed consent, either obtained verbally or signed. The overall identified overpayment for the plan exceeded $33,000.

Key takeaways for dental payers

After the dental plan informed the provider of Cotiviti’s findings, the provider’s office conducted an analysis of its internal claim systems. This resulted in the provider learning that their internal systems were set up incorrectly and automatically applying the owner’s National Provider Identifier (NPI) on all claims. The dental plan then set the provider up on a corrective action plan to be followed.

To mitigate future FWA scenarios and avoid the often costly, burdensome process of recovering overpayments, dental payers should consider the following best practices:

• Conduct proactive analysis of procedures to identify outlier providers for review. Working with an external partner that has access to cross-payer claims data and analytics can significantly enhance these efforts, as FWA patterns often can only be identified across multiple payers.
• Conduct medical record audits. Request and review medical records to ensure the provider’s documentation coincides with billing requirements, then recoup any overpayments identified.
• Educate providers on proper billing and documentation guidelines for restorative procedures. In some cases, dental offices work with outside billing consultants that may not be aware of clinical and billing best practices, which can result in overbilling.
• Educate providers that they should be checking their claims clearinghouse rules and system edits. As observed in the outcome of this particular investigation, inappropriate billing practices can stem from internal systems errors.