A claim submitted to Delta Dental of New Jersey must accurately reflect the actual service or procedure that was rendered. An office cannot bill for a service that was not performed.
Occasionally, the submission of a service or treatment that was not actually performed may be the result of an office error. Other times, however, the addition of a service or treatment that was not performed is intentional. It may involve a deliberate attempt to obtain a benefit to which the office is not entitled. Alternatively, it may involve an attempt to obtain a benefit to which the patient is not entitled, either to defray the cost of a non-covered service or to apply to the patient’s account in order to offset a co-payment or deductible. In either instance, submitting a claim that includes a service or procedure that was not performed in order to obtain a benefit that neither the office nor the patient is entitled is considered a fraudulent practice.
An example of an inappropriate billing practice includes the office that submits a fluoride treatment on every claim where a child prophylaxis was also performed. It may be the office protocol to combine this particular combination of services on the claim. But, if the fluoride treatment was not actually administered, it should not be submitted on the claim.
Another example involves the patient whose policy includes an annual limit of two prophylaxes. If the patient has met the limitation, a third prophylaxis cannot be submitted as a root planning and scaling or periodontal maintenance. If the root planning and scaling or periodontal maintenance procedure was not actually performed, it should not be submitted on the claim.
A third example is the office that takes full mouth radiographs but submits the claim as a combination of four bitewings and two periapicals in order to bypass the potential contract limitation for full mouth series radiographs.
To avoid these situations, offices should develop protocols to ensure that the treatment or service reflected on the treatment record and the patient’s financial ledger match the service that was actually rendered as it appears on the claim.
Delta Dental reviews claims and office practices to verify that services that appear on the claim are the actual services that were rendered.
To report any suspected fraud to Delta Dental of New Jersey:
- Call our fraud hotline: (888) 696-3262
- Email: reportfraud@deltadentalnj.com
- Fax: (973) 944-4573
Write to:
Delta Dental of New Jersey
Special Investigations Unit
1639 Route 10
Parsippany, NJ 07054
