Compliance is essential to the short-term and long-term success of any dental practice. While most dentists are concerned about the risks that over-coding and over-billing can create, under-coding is also a serious issue. In fact, under-coding is considered dental fraud in the same fashion that over-coding is. Failing to accurately state what services were performed and deliberately under-coding both put your practice at increased risk for an insurance provider audit and steep fines.

Why Is Under-Coding a Problem?

Many professionals are skittish about over-coding and getting in hot water by billing for services not rendered. While over-coding might get more attention from Federal and State law enforcement authorities, under-coding is not a solution for practices concerned about over-coding. Whenever the code you bill does not accurately represent the service rendered, you are committing dental fraud. Aside from breaking the law and your contracts with insurance agencies, you are also putting yourself out of compliance.

Why Do Dentists Under-Code?

Many practices misunderstand how insurance providers flag potential fraud. Some dentists think that providers are more likely to investigate insurance claims if billed services have high reimbursement rates. In reality, insurance companies can elect to review any and all claims that you make, regardless of amount or reimbursement rate. If insurance companies do review your claims, they will not necessarily be paying attention to reimbursement rate amounts. Instead, they will be ensuring that all codes billed match patient records. If records don’t back up the code that was billed, the company can deny reimbursement.

What are insurance companies looking for when they examine a patient record?

  • Symptoms
  • Diagnosis
  • Documentation to back up the diagnosis (X-rays, exam notes, etc.)
  • Treatment
  • Medications prescribed
  • Health risks associated with the treatment

Under-Coding Puts Your Practice at Risk

Part of owning and managing a dental practice is taking steps to avoid unnecessary risk, and over-coding and under-coding both put you at a heightened risk of issues. Insurance companies make contracts that reimburse your practice for valid claims that satisfy their documentation requirements. If you are regularly under-coding and you are flagged for your irregular billing, you could be investigated for fraud. Under-coding also harms your practice by creating false utilization patterns that make your practice an outlier, which is never something you want to be!

Keep Your Practice In Compliance with Help from APEX

APEX Reimbursement Specialists can ensure that your dental practice is ready for any type of compliance audit. Whether you need a refresher on proper coding procedures or need to overhaul your billing procedures, our experts can help. Contact our team today by calling (410) 710-6005. We look forward to working with you to make your practice a more profitable place.