Insurance fraud, my responsibility


#1

Hello all. I am a former dental hygienist. I say former because I’ve been stay at home mother for about six years and my license to practice has expired, but I suppose once a hygienist, always a hygienist lol… Anyway, over the years I have worked at many different offices with different ethical standards.

There was one office in particular I quit working at due to their flagrant abuse of insurance filings. They constantly post dated claims, meaning, called patients in for cleanings earlier than their six month due date to fill the schedule, and “held” the claim to date it for a different day so it would be paid. When I told the office manager I wasn’t comfortable signing my name to the chart with dates that would later be changed she was shocked. She said, “oh I’m sure your other office [that I worked at part time as well] does this too!” No, absolutely not, it’s fraudulent and can end up in jail time and loss of licensure and insurance.

At any rate, fast forward to this month. I was at my own dentist for a consultation on some problems I have been having and the treatment plan for a special bite adjustment and mouth guard was $3500. I said, there is simply no way I can do this. The doctor’s wife is the office manager and she said, oh not to worry, I should pay what I could and she would bill the insurance for a little of this and a little of that until the balance was paid.

I didn’t answer to that because I was pretty shocked. Most dentists know perfectly well that mis billing on purpose is against the law, and can result in serious repercussions including not being allowed to file with them any longer, and having to reimburse previous claims etc. not to mention the federal crime aspect. Every claim has a line on it that says under penalty of federal law I swear that this information is true to the best of my knowledge.

So here is my problem- she didn’t DO this, since I declined treatment, she just suggested it. I keep track of my account and haven’t seen anything billed incorrectly. I really hate to get involved, but any office that is misappropriating insurance monies is of course costing us all. However, I feel as though I have this in my head and I am not telling the insurance company something they may need to know.

So, should I call united health care and tell them, or leave it alone? Any thoughts? Thank you.


#2

If you find irregularities on YOUR billing, you should let your insurance know. Otherwise, it is just speculation.


#3

I’d be very surprized if the insurance companies didn’t know about this already. They probably don’t care, so long as they can up the premiums & count their bonuses!


#4

If it was openly suggested like that I would definitely be concerned AND I would be inclined to inform the insurance company of that as it is a fact. Trust me they do care! And no they may not know about it.

You must be careful in accusing this Dentist/ office though. I would tell the insurance company that you were encouraged to do something which is illegal and you are merely concerned about it. They will investigate it. If there is nothing going on, then its a non-issue. On the other hand…

I work for an insurance company (not this one you are speaking of) and they take this very seriously. No one gets big bonuses from that non-sense. Sorry to other poster that suggested that, but that’s not how it works. When the insurance company gets ripped off, then guess who pays for it!? Not them. You and I do! Besides insurance fraud is a federal crime.

Let your conscience be your guide!


#5

Good answer. I am not sure how what the OP is describing is fraud. If the dentist only makes a claim for services rendered what is the problem? Why can’t this be done one step at a time?

I for one think insurance companies are the biggest rip off of all times. I don’t suggest defrauding them. I do think we would be better off if most of them didn’t exist or at least if they concerned themselves with services rendered only. It seems they are always trying to find a way to not pay anyone anything, even legitimate claims. Just my vent.


#6

It’s fraudulent because they would be billing for services they didn’t render, specifically to get the dollar amount of the service they did render, paid eventually. So for example the occlusal therapy they wanted to do is $3500, and if I could pay about $1000, they would falsely bill for various procedures until the rest of the $2500 or so is paid off.

It’s fraud bc number one, those procedures wouldn’t have been done, and number two, they would be accepting “insurance only” payments for those false claims which is also a no no. They and the patients have signed a contract that agrees how much they will pay for any and all coded procedures. It’s very straightforward in dental, no confusing diagnostic codes etc. it’s either covered, or not covered. If it is covered, it’s at a percent. So if they pay 50%, they patient has to pay his 50% as well. To accept only the insurance portion is not abiding by the agreement.

But, since they only suggested it to me and haven’t actually done it, I’m going to just leave it alone. If I see anything whatsoever that says they are actively doing this, I’ll call. It just burns me up that it is taken so casually.

Thanks for the input.


#7

Leave it alone. They were just trying to help you out by fudging the billing process with the insurance company, so you could get your treatment. If there are any other irregularities with other patients, it is not your concern. If you are really disturbed by this, then you should consider changing dentists.


#8

Engaging in such unprofessional behaviour (incorrect billing) will reflect on the clinic’s standing. Such practices will backfire if ever an audit is done (there are penalties for that similar to Medicare fraud). Being a health professional myself, I’m required to uphold the high standards of the profession. Dishonesty is not tolerated nor should we allow a colleague of ours to do so.


closed #9

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