Is Under Coding a Compliance Risk?

Most dentists understand that over-coding is a serious compliance risk. However, did you know that under coding can also be considered dental fraud? Deliberate under coding, or falsely stating what services were performed, puts your practice at risk for a steep fine or investigation from an insurance provider.

Is Under Coding a Problem?

Unfortunately, organizations including hospitals and dental practices regularly practice under coding to avoid coming under scrutiny and getting audited. Under coding occurs whenever the code that is billed does not properly represent the service that occurred. Aside from contributing to lost revenue left on the table, it is a form of fraud. Over coding, or overstating the procedures that were performed, is also a compliance risk.

The Misunderstanding Behind Under Coding

The belief that causes many dentists to under code is that insurance companies are more likely to investigate claims if the billed service has a higher reimbursement rate. In reality, there is no way to stop an insurance company from reviewing any claim that you make.

When insurance companies do review a claim, instead of looking for low-reimbursement rate services, the auditor will be looking for the codes to match the patient records. If the patient’s medical record does not match the code billed, the insurance company will deny reimbursement.

What do insurance companies look for in a patient record? Symptoms (if any), diagnosis, documentation supporting the diagnosis (X-rays, etc.), care, treatment, medications prescribed and any health risks associated with the treatment.

Under Coding Is a Compliance Risk

At the end of the day, insurance companies exist to reimburse your dental practice for valid claims that meet documentation requirements. If you routinely under code and your practice is flagged for irregular billing, the insurance provider might put you under investigation for fraud. More importantly, under coding can also create false utilization patterns that flag your practice as an outlier. This might also make you a target for an insurance investigation or compliance audit.

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.