Dental professionals seek to provide the highest level of service and support to their patients. That includes making sure that all procedures are essential and that the charges for those procedures are in compliance with current standards. When a claim of dental insurance fraud is made against a practice, the results can be devastating. Fortunately, there’s a lot that a dental insurance fraud lawyer can do to defend the client. Here are a few things that you should know about this type of fraud and how your practice can be defended.
Understanding The Basics of Dental Insurance Fraud
There are essentially three points that must be established in order to demonstrate that fraud has taken place. The first has to do with intent. There is the need to determine if the dental professional set out with the intention to defraud the patient in some way. For example, there as an deliberate decision to add an additional percentage to the charge for services rendered, even though that percentage as above and beyond the established rates for the service.
Another point that must be addressed is deception. Did the dental professional make full disclosure in advance about all the charges associated with the dental procedure? At any point, was something left out that the patient needed to know before choosing to proceed with the treatment? When proven, deception goes hand in hand with the creation of charges that the patient was not expecting to incur.
The third issue to consider has to do with unlawful gain. This is a deliberate attempt to use some type of bookkeeping magic to increase the charges to the patient and seek to secure a larger payment from a dental insurance company. An example of how this can be accomplished is by performing what is known as upcoding. As defined by the American Dental Association, upcoding means filing a claim for a more complex and expensive procedure when in fact a simpler and less expensive procedure was conducted. Choosing to bill for a root canal when a simple extraction took place is a classic example of upcoding.
Seeking Legal Help
If a claim of fraud is lodged against a dental practice, securing the services of a dental insurance fraud lawyer is the first thing that must be done. During the initial consultation, it helps to bring along any documentation received from the representatives of the insurance company or the patient. Be prepared to discuss the nature of the charges as part of that initial discussion.
Once the lawyer accepts the case, expect for a complete review of the client’s accounting records to take place. The goal is to ensure that those records are maintained in accordance with generally accepted accounting practices. It’s possible that the current situation has arisen because something was posted inaccurately by accident. There’s also the chance that the review will find that outside of a couple of coding errors, the records of the practice are in excellent condition.
A review of the patient’s record, including when procedures did take place and how they were billed to the insurance company, is also part of the standard preparation for a defense. When there is some doubt about the legitimacy of a filed claim, the lawyer may seek to arrange for an independent dental expert to examine the records, X-rays, and other documentation to determine if the procedure on the claim was actually performed.
Settling on a Plan for the Defense
Once the lawyer has compiled the details of what actually transpired, the structuring of the defense will begin. When the matter came about due to basic human error and there is no evidence of an intent to defraud, it’s possible to resolve the situation quickly. There may still be penalties involved, depending on if there are indications of recurring errors with the record keeping, such as a habitable use of the wrong code for a specific procedure.
If possible, the lawyer will seek to reach a settlement with the insurance company. This is usually the most expeditious way to dispense of the matter when there is no proof of an intent to defraud and plenty of reason to believe the issue was the result of an oversight or an incorrect posting in the billing system.
Never take claims of fraud lightly. Seek legal representation and cooperate fully with the lawyer. In the best case scenario, the matter can be investigated and settled quickly and discreetly.
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