By: Angela Holland
In the world of dental insurance, accuracy isn’t just important, it’s essential. When it comes to submitting dental claims, one of the most critical pieces of information is the rendering provider, the licensed dentist who actually performed the service.
Whether you’re a single-practice office or part of a larger dental network, it is crucial that claims are submitted under the correct rendering provider’s name and National Provider Identifier (NPI).
Failing to do so, for any amount of time, is not just a simple mistake, it’s insurance fraud.
In this blog, we will explore why submitting dental claims under the wrong provider constitutes fraud, the risks it poses to your practice, and how to ensure that all claims are accurate and compliant.
What Is the Rendering Provider and Why Does It Matter?
I know this is silly to clarify, but I hear of this fraudulent process daily, I prefer to be as clear as possible since knowledge is power for all of us!
The rendering provider is the dentist who directly provides the care to the patient. This is the individual whose services are being reimbursed by the insurance company, and their name, NPI, and credentials must appear on the dental claim submitted to the insurance carrier. The rendering provider is accountable for the diagnosis, treatment, and patient care, and their identity must be properly reflected in the claims submitted for insurance reimbursement.
For example, if Dr. Johnson performs a root canal, and Dr. Lee in the same practice is the one submitting the claim, the claim must still list Dr. Johnson as the rendering provider, as they are the one who delivered the treatment.
Why Submitting Claims Under the Incorrect Rendering Provider Is Insurance Fraud
Insurance fraud is the intentional misrepresentation or concealment of information with the intent to deceive or mislead in order to gain an unauthorized benefit, such as improper reimbursement.
Submitting dental claims under the wrong rendering provider, even if done unintentionally, falls squarely under this definition of fraud, especially if it occurs repeatedly.
1. Misleading the Insurer About Who Provided the Service
When a dental claim is submitted under a provider’s name who did not perform the procedure, it creates a false representation of who delivered the treatment.
This misrepresentation is considered fraudulent billing because the insurer is paying for services as if they were provided by a different provider than the one who actually delivered the care. Even if the provider submitting the claim is licensed or works within the practice, the claim must still accurately reflect the actual rendering provider.
Insurance companies expect claims to reflect the dentist who is legally and professionally responsible for the treatment. When this is not the case, it’s akin to misdirecting funds. Whether it’s for a new provider in the practice, a temporary provider, or an established provider who might not have seen the patient, submitting claims under the wrong provider misleads the insurer—and that’s fraud.
2. Potential for Over- or Under-Reporting of Services
Submitting claims under an incorrect provider can also result in improper payments that could amount to overbilling or underbilling. For example, one provider may have a higher reimbursement rate for certain procedures, while another has a lower rate.
By submitting claims under the incorrect provider, the practice may either overcharge the insurer or underreport the true nature of the care provided, which can lead to incorrect reimbursement or lost income.
In many cases, submitting claims under a provider who is not eligible to be reimbursed for specific procedures could result in underpayments, which ultimately affects the practice’s cash flow.
On the other hand, submitting claims under a provider who is reimbursed at a higher rate could lead to overpayments, triggering an investigation, claim adjustments, or an audit.
3. Violation of Insurance Contracts and Regulations
Most dental insurance contracts contain clauses that specify how claims should be submitted, and one of the most basic stipulations is that the rendering provider’s information must match the provider who performed the service.
By submitting claims with incorrect provider data, you’re not only violating the insurer’s specific rules but also breaching the terms of your contract with the insurance company.
From a regulatory perspective, dental practices must follow specific billing codes, practices, and guidelines laid out by both the insurer and governing bodies. Misrepresenting the rendering provider goes against these rules and can trigger severe consequences, including contract termination with the insurer, loss of in-network status, and even legal repercussions.
4. The Risk of Severe Penalties and Legal Action
Insurance fraud is a serious offense. If caught, dental practices can face hefty fines, penalties, and even criminal charges. Even if the improper submission of claims was done out of error or misunderstanding, the law generally treats it as fraud if there is an intent to deceive. Civil penalties for insurance fraud can range from thousands to millions of dollars, depending on the severity and the extent of the fraudulent activity.
In addition to financial consequences, practitioners who engage in fraudulent billing practices risk losing their professional licenses, facing disciplinary actions from state dental boards, and being excluded from participating in government-funded programs like Medicaid and Medicare.
The repercussions of fraud can also tarnish the reputation of the practice, making it difficult to regain the trust of patients and insurance providers. In extreme cases, a practice could be forced to shut down entirely due to the fallout from fraudulent billing practices.
5. Patient Trust and Ethics
As healthcare providers, dental professionals are entrusted with providing care that is both medically necessary and ethically sound. Submitting claims under the wrong rendering provider undermines this trust, as patients may not be aware of discrepancies in billing.
When claims are incorrectly submitted for services that weren’t actually rendered by the listed provider, it can compromise the integrity of the practice and raise concerns about the ethical conduct of the practice.
Patients expect their insurance companies to pay for the treatments they receive from the providers listed in their insurance contracts. If a dentist’s name is fraudulently listed as the rendering provider, it misleads both the insurer and the patient.
Avoiding Insurance Fraud: Best Practices for Accurate Claim Submission
To ensure that your dental claims are submitted accurately and in compliance with insurance rules, follow these best practices:
1. Verify Provider Information Regularly
Ensure that every dentist in your practice is credentialed with insurance carriers and that all information is up to date. This includes NPI numbers, tax IDs, and any other relevant identifiers.
Even if a new provider is joining the practice or you’re going through an acquisition, take steps to ensure the provider’s information is properly integrated into your system and reflected on all claims.
2. Submit Claims Based on Actual Care Delivered
Always submit claims under the provider who performed the service. If a new provider is joining the practice or if there is a change in the practice ownership, ensure the correct provider is listed on every claim for as long as necessary.
3. Training and Communication
Educate your staff and team members about the importance of proper billing practices. Everyone involved in the billing process should understand that submitting a claim under an incorrect provider—even by mistake—could be considered fraud. Regular training and clear communication can help prevent errors.
4. Review Claims Carefully
Before submitting claims, review them carefully for accuracy. Double-check that the right provider’s name, NPI, and credentials are listed for each procedure performed. Catching errors before submission can prevent costly mistakes down the line.
In Conclusion
In conclusion, submitting dental claims under any provider other than the rendering provider is a form of insurance fraud. Even if this is done unintentionally or as a result of an administrative oversight during a transition or acquisition, the consequences can be severe. Not only can it result in rejected or delayed claims, but it also exposes your practice to legal, financial, and reputational risks.
Ensuring the correct provider is listed for each service is crucial for maintaining compliance with insurance contracts, protecting your practice’s financial health, and preserving your professional reputation.
In the world of dental billing, accuracy isn’t just important—it’s mandatory.
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