Services Submitted on Claims Must be Performed, or It's Fraud

A dentist must only submit claim forms to third-party payers that reflect dental services or procedures actually rendered. 

Billing for a service that has not been performed may be intentional. “Extra” unperformed services or procedures may be added to a claim form because reimbursement for these services may cover the cost of non-covered services or defray the patient’s co-payment or deductible responsibility. 

Conversely, submitting a claim for payment for services or procedures that do not appear on the patient’s treatment chart or financial ledger may be the result of an office policy. For example, it might be standard office policy to add a fluoride treatment to every child prophylaxis because this particular combination of services is usually performed. In some cases, the fluoride treatment may not have been administered to a specific patient. 

In both cases, submitting for services or procedures that have not been performed is one of the unacceptable billing practices reviewed during claim verification. Billing in this manner can result in overpayments that are recoverable. If a claim form is intentionally submitted for services or procedures that have not been performed, it can be considered a fraudulent attempt to gain benefits. 

For more information, please refer to:

• New Jersey State Board of Dentistry, Administrative Code [NJAC 13:30-8.10] 
• The General Statutes of Connecticut [Volume 7, Title 20, Chapter 379 Sec. 20-114]
• The Delta Dental of New Jersey Participation Agreement
• The Delta Dental of New Jersey Handbook for Participating Dentists, Chapter 11, Claim Verifications