White Paper: Enhancing dental payment accuracy to combat FWA

In the realm of dental care, financial losses due to fraud, waste, and abuse (FWA) present a significant challenge. Dental treatment amassed $165 billion in healthcare spend in 2022, with an estimated 3-10% of payments comprising FWA. Overtreatment and other intentional or unintentional wasteful and abusive practices lead to increased costs and unnecessary procedures, placing strain on insurers and impacting patient trust.

Prevalence and impact of FWA in dental billing

Unlike medical procedures that often require pre-authorization, many dental procedures are performed at the discretion of the dentist. Dental practices, often owned by larger companies, may have standardized treatment plans rather than patient-specific plans, cultivating an environment that can foster overtreatment, especially when bad actors exploit the system.

Patients with Medicare Advantage (MA) plans are vulnerable due to the variety of benefits offered for dental care, with some plans offering a no-limit spending option on essential procedures. This flexibility can be exploited by deceptive practices, leading to overtreatment and inflated costs. For dental plans, this can translate into millions of dollars in improper payments each year. Individual cases of overtreatment, such as unnecessary crowns or root canals, can cost hundreds to thousands of dollars each. When aggregated, the financial impact is substantial.

Higher premiums for policyholders, increased administrative costs for auditing and resolving disputes, and the erosion of trust in dental plans are some of the consequences of FWA. These issues not only affect the financial stability of dental payers but also compromise the quality of care for patients.

Detecting common schemes with dental utilization review

FWA in dental billing can take many forms, including overtreatment, upcoding, and repetitive add-on procedures. Some common examples include:

• Add-on codes for crown procedures: Billing for additional procedures that were not performed.
• Upcoding: Billing for a higher-level procedure than what was performed.
• Overtreatment: Performing unnecessary procedures, such as fillings or crowns on healthy teeth, which can weaken the tooth and reduce longevity.
• Billing under different providers' names: In multi-dentist practices, procedures may be billed under different names to avoid detection.

Dental utilization review, including the analysis of x-rays and documentation, is crucial in verifying the necessity of procedures. This helps ensure that treatments are appropriate based on the patient's condition and codes are scrutinized for clinical and medical necessity, enhancing the accuracy of claims and reducing FWA.

Detecting and stopping FWA is essential for the performance of dental plans to reduce financial losses, discourage overtreatment, and protect member benefits. Dentists should work with patients to create individualized treatment plans that consider their health, financial situation, and wellness goals. By implementing strong payment integrity programs, dental plans can improve outcomes for all stakeholders.