Insurance Fraud Awareness

Do’s and Don’ts

Member Awareness

The following list of Do’s and Don’ts are simple ways you can help prevent providers from committing insurance fraud, and prevent you from avoid becoming a victim.  Be sure to contact the appropriate authorities if you think you are a victim  or witness to insurance fraud of any type.

Top 5 Member Do’s and Don’ts When it Comes to Insurance Fraud

Do:

  • Check your Explanation of Benefits statement (EOB) for accuracy
  • Keep your insurance information secure
  • Question any charges or services that appear to be incorrect
  • Know your plan benefits and responsibilities
  • Obtain receipts for all of your payments

 

Don’ts:
Do not ask your dentist to:

  • Change the amount of the fees charged for any of the services billed 
  • Submit a date of service that is not accurate
  • Submit for services or procedures not performed
  • Omit additional insurance coverage and payments from your claims
  • Omit information regarding any discounts you received

Dental Office Awareness

Delta Dental considers all of the following unacceptable billing practices in the dental office:

  • Billing services based on the preparation date rather than the completion date
  • Charging a Delta Dental-covered patient in excess of your fee or Delta Dental's approved fee level
  • Failing to disclose discounts and/or waiver of co-payment
  • Failing to disclose other coverage for the dental services
  • Misrepresenting the rendering dentist
  • Misrepresenting actual treatment rendered or the actual treatment date
  • Submitting for services previously paid
  • Submitting for services not actually performed
  • Submitting claims which overstate the fee that will be accepted as payment in full

 

Important Notes:

Delta Dental participating dentists may not submit any claims to Delta Dental for services performed by dentists who are not participating dentists with Delta Dental on the date(s) when the services were performed.

To receive direct payment as a participating dentist, every dentist in a dental practice must sign a participating dentist agreement and credential with Delta Dental as a participating dentist.

Usual Fee - Participating dentists must file their “usual” fees as defined in the Bylaws of Delta Dental of New Jersey, Inc. “Usual” fee is the fee that the dentist most frequently actually charges to and collects from his/her uninsured patients as payment in full, less any discount which is regularly offered to patients, other than a discount which reasonably reflects the time value of money. (i.e. where the amount of the discount is essentially the same as the amount of interest that the dentist would reasonably expect to earn by receiving the payment on an accelerated basis). For purposes of this regulation “uninsured” means without dental coverage, but exclusive of patients covered by governmental assistance programs such as Medicaid.

Uninsured means without dental coverage, but exclusive of patients covered by governmental assistance programs such as Medicaid.

Patient discounts are permitted as long as the discount or any waiver of co-payment responsibility is noted on the claim form.When extending a discount, it should be applied to the fee for the service rendered so that the net fee submitted to Delta Dental and the net fee charged to the patient are both reduced.(Discounted fees must be specified on claims submitted for payment).