Illegal Dental Billing Practices

The laws regulating billing and insurance claims for dental professionals in Texas, are incredibly complex. Knowing the laws is key, especially if you have been accused of illegal dental billing practices. Allegations of improper billing practices can lead to criminal charges, discipline against your dental license, large fines or recoupment, loss of credentialing with government and private payors, and the loss of reputation. At Lype Dest Smith Lawyers, we are experienced in defending dentists and dental practices accused of illegal or improper billing practices. 

Understanding Dental Billing Fraud

Generally speaking billing fraud involves knowingly submitting false or misleading charges or claims to a patient or their insurance providers. Unfortunately dental fraud is widespread and this has led to more and more scrutiny paid to claims and practices that are potentially fraudulent. Dentists in Texas are further pressed by very strict state laws and insurance regulations demanding exactness in their billing. Whether related to overbilling, fabricated claims, or mere mistakes, such issues can snowball and lead to severe consequences if not handled with due care.

Illegal Dental Billing Practices

It is important for any Texas dentist to know some of the most common illegal dental billing practices to maintain licensure and compliance. This section identifies some examples of billing practices that can put a dentist in legal jeopardy.

Double Billing

Double billing is when a dentist submits the same claim for a procedure more than once in order to maximize reimbursement. For example, charging twice for placing one crown is a violation of insurance policies and may trigger audits and penalties. Checks should be instituted by dental practices to avoid duplicate claims and ensure clean submissions.

Billing for Services Not Rendered

It is a violation of regulations to claim reimbursement for phantom treatments or procedures never performed. Oftentimes this occurs by accident when a planned procedure is not performed and the practice’s front office is not careful reviewing claims prior to filing.  The American Dental Association (ADA) emphasizes the importance of proper documentation and record keeping to avoid allegations. Regular self-audits can help in locating discrepancies early. 

Upcoding

Upcoding involves exaggerating the complexity or cost of a procedure to secure higher payments, such as billing for a surgical extraction when only a simple extraction was performed. Again, this type of error frequently happens by accident when the final procedure ends up being less complicated than expected during treatment planning. Medicaid and Texas law underscore the importance of coding accuracy, making compliance critical for dentists.

Unbundling

Unbundling is the act of billing separately for procedures usually grouped together to increase reimbursement. For example, charging individually for components of a dental implant package, instead of using one fee. Dentists should avoid unbundling as it often conflicts with insurer policies and could trigger investigations.

Waiving Co-Payments/Deductibles

Waiving patient co-payments may appear patient-friendly but can violate Medicaid and agreements with insurance providers. Texas practices should ensure their teams understand the importance of collecting co-payments and deductibles.

Altering Claim Forms

Manipulating claim forms with changes in dates, procedures, or costs may constitute criminal fraud. As noted in a course on fraud presented by the Dental Ethics Center, maintaining records that are accurate and truthful is necessary to maintain compliance. Dentists should establish tight controls to prevent unintentional errors or deliberate misbehavior.

Ethical Billing in Dentistry: Best Practices

To avoid the pitfalls of illegal dental billing practices, adhere to ethical standards by:

• Ensuring all documentation is accurate and comprehensive.
• Hiring staff trained on proper coding and billing practices;
• Regularly retraining staff on the latest billing compliance updates;
• Utilizing reliable practice management software to minimize errors;
• Performing periodic self-audits; and
• Partnering with experienced attorneys for routine compliance checks.

Ethical billing for any Texas dental practice also means building trust with the patients and insurers. Communicating procedures, costs, and coverage in a very transparent manner builds lasting relationships.

Legal Consequences of Dental Fraud

Penalties for violations in dental billing are severe, some of which include:

• Hefty fines and restitution demands.
• Disciplining of, and potential loss, of your dental license;
• Loss of credentialing with insurers and Medicaid;
• Criminal charges.

Texas-specific guidelines can make the whole process of defense really very complex. Investigations can may involve the Texas Dental Board, Office of the Inspector General, insurance companies, and even federal agencies like CMS. Know and follow the laws that govern dental billing to protect your practice and career.

Protect Your Dental License – Contact Lype Dest Smith Lawyers

Accusations of improper dental billing practices can put your career and reputation at risk. At Lype Dest Smith Lawyers, we offer focused legal representation to dental professionals. Contact us today at 512-881-3556 or online to protect your future.

Dan Lype

Not afraid to go to court when necessary, Dan has successfully litigated cases all the way to the Supreme Court of Texas. Dan also prides himself on being readily available to clients throughout their cases. He strongly believes effective representation should be a collaborative effort between a client and their attorney.

Years of experience: 15 years
Bar number: 24065658
Location: Austin, TX

Dan Lype

Not afraid to go to court when necessary, Dan has successfully litigated cases all the way to the Supreme Court of Texas. Dan also prides himself on being readily available to clients throughout their cases. He strongly believes effective representation should be a collaborative effort between a client and their attorney.

Years of experience: 15 years
Justia Profile: Dan Lype
Bar number: 24065658
Location: Austin, TX