Fraud, waste, and abuse (FWA) continue to challenge dental plans as overtreatment, miscoding, and inappropriate billing practices drive unnecessary costs. With an estimated $198 billion spent on dental care in 2025, and approximately 3–10% of these payments lost annually to FWA, dental payers need more effective ways to identify suspect claims. Growing coding complexity and evolving billing practices make improper claims harder to detect through traditional editing alone.
Unlike many medical procedures, common dental services such as crowns may not require pre-authorization tied to a documented diagnosis. This can create opportunities for overtreatment or unsupported billing, especially when practices face pressure to meet revenue or performance goals.
The financial and operational impact of dental FWA extends beyond the improper payment itself. Suspect billing patterns such as unnecessary buildups, upcoding, overtreatment, repetitive add-on procedures, or billing under different provider names can increase administrative costs and strain provider relationships. When these issues are addressed only after payment, plans may be forced into costly “pay-and-chase” recovery efforts that consume internal resources and create additional friction. But a smarter prepayment approach can help plans strengthen claim accuracy, protect resources, and reduce administrative burden.
Read our new white paper for insight into:
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Emerging risks and schemes in dental claims
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How prepay review can reduce erroneous payments while assisting internal teams
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How national and proprietary edits, clinical guidelines, member history, and plan-specific rules work together to surface emerging risk patterns
By combining analytics, configurable rules, and professional review of documentation and treatment history, dental plans can improve payment accuracy while better protecting plan resources, provider trust, and member benefits.
