FWA Briefs

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Dental FWA – Upcoding, Misrepresentation and Diagnosing Unnecessary Treatment

  • by Cindy Gallee, JD, RHIA, CHC
  • Jan 16, 2018, 10:30 AM

Dental fraud, waste, and abuse (FWA) is often unchecked as most Payer’s dental insurance line represents 10% or less of their total business.  The National Health Care Anti-Fraud Association (NHCAA) estimates $68 to $226 billion is lost annually to Fraud, Waste and Abuse (FWA).  This means up to $ 22.6 billion in FWA is overlooked annually.  

Here are two examples of common dental fraud, waste, and abuse include CDT codes D4341/D4342.  These procedures are indicated for patients with periodontal disease who require scaling and root planing due to bone loss and subsequent loss of attachment.  These involve instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus.  

Take the example of a first-time patient.  Part of the first visit will be an initial oral examination (D0150).  As most patients do not suffer from periodontal disease, one would expect to see that patient follow up with regular visits twice a year Periodic Evaluation(D0120), Prophylaxis(D1110).  

Some providers look for the presence of plaque, calculus or staining during the initial oral examination. They are symptoms, but not necessarily indicative of periodontal disease.  They then call the insurance company to determine benefit coverage for D4341/and D4342.  Why?  Because D4341/D4342 carry a higher reimbursement rate.  In addition, for periodontal patients, many insurance companies allow four annual Periodontal Maintenance (D4910) visits instead of the standard two Periodic Evaluation(D0120) visits and two Prophylaxis (D1110) visits.  To top it off, because D4341/D4342 are periodontal procedures, local delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue (D4381) and drugs or medicaments dispensed in the office for home use (D9630) can be billed.  If benefits are confirmed, the providers upcode what should have been D1110 to D4341/D4342 which is more than double of the revenue.  Worse, antimicrobial agents and drugs or medicaments are often not covered by insurance and come straight out of the patient’s pocket!  

The key to detection is assessing the frequency of D4341/D4342 across a provider’s book of business.  There should be a higher frequency of D1110 (Prophylaxis), D0120 (Periodic Evaluation) and D0150 (Comprehensive Examination).  If not, there is an indication that an FWA issue may exist.  

Context 4 Healthcare has delivered Payment Integrity solutions for more than a decade.  Payment Integrity and reference-based-pricing is Context 4 Healthcare’s only business.  Being independent allows us to provide unbiased feedback and best of breed approaches to compliance.  Our Dental Payment Integrity solution is a real-time, cloud based service for editing and FWA detection.  


Find out more on our website: https://www.context4healthcare.com/solutions/payment-integrity/dental-payment-integrity

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