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How claims examiners can detect dental fraud

We had a chance to see Dr Richard Celko DMD speak at the Canadian Health Care Anti-fraud Association Conference on Sept 21st, 2012 on how he determines if a dental claim is fraudulent. Here are some of the higher-level insights from the seminar.

  • Dr Celko estimates that 15% to 20% of dentists are either fraudulent or have questionable practices in terms of billing both the government and private plans.
  • If a dentist submits grainy, poor quality images, it is a red flag: are they trying to hide something? Or make it difficult for the examiner to see what is going on? Or do they just not invest in quality imaging software?
  • Any time you see scribbles instead of printed or typed out text, it’s a cause for concern. “It’s what people do when they try to hide things,” said Dr Celko. “If the quality of submission of claim is high, there’s a low risk for fraud. A quality submission can generally mean a higher quality clinic and person.”
  • Root canal obstructions and crowns are large areas for fraudulent activity.
  • Pulpotomies and stainless steel crowns are big dollar items and thus wrought with fraud.
  • ‘Upcoding’ is huge – going the next level up for reimbursement.
  • There tends to be more fraud on the government reimbursement side than the private payer side. Private insurers tend to be more aggressive at catching and cracking down than government.
  • Side fact: the amount of money spent on orthodontics in Texas paid by Medicaid is more than what Medicaid spends in total for the entire United States combined for orthodontics.

Fraud among Dental Receptionists

We also spoke to one fraud detector at a large insurer who said that they’re finding a lot of fraud done by dental receptionists. Here’s what they would do:

  • Submit a false claim to the insurance company
  • Pockets the cheque when it is mailed in
  • Reverses the claim in their own system
  • Deposits the cheque into her ATM and pockets the amount fully
  • The way banks work is that they do not question a cheque submitted through an ATM unless the issuing party or intended recipient goes after the bank and questions it. Since the receptionist had reversed the claim in their system, the dentist is not expecting the money and has nothing to question.

About the speaker

Dr. Richard Celko – National Dental Director of Utilization Management and Clinical Integrity, Avesis
Richard M. Celko DMD, MBA is a graduate of the University of Pittsburgh, School of Dental Medicine. He completed his General Practice Dental Residency at Montefiore Hospital. He received his Master in Business Administration from Indiana University of Pennsylvania.

He was also a Clinical Instructor at the University of Pittsburgh, School of Dental Medicine in the Departments of Restorative Dentistry and Oral Diagnosis.

Prior to working for Aetna, Dr. Celko was in private practice for nearly 10 years. Dr. Celko worked for Aetna for 11 years and was their National Dental Director of Utilization Management.

Dr. Celko is a former president of the American Association of Dental Consultants and former corporate representative to numerous committees and organizations including the ADA, AAOMS, AAE, AAP, AAO and Oral Health America. He has lectured nationally on Dental Fraud and Coding and is a veteran lecturer for the National Health Care Anti Fraud Association (NHCAA). He is a Certified Dental Consultant and holds the AHFI (Accredited Health Care Fraud Investigator) designation from the NHCAA. Dr. Celko is a former Chief Dental Officer of New York based P & R Dental Strategies, Inc. and is currently the National Dental Director of Utilization Management and Clinical Integrity for Avesis, a National Hearing, Vision and Dental Plan.