Going back more than five decades, the various expenditures measured include healthcare goods and services, the net cost of health insurance, public health activities, government administration, and investments related to healthcare.
The data released by the NHEA or National Health Expenditure Accounts are generally considered to be the official estimates of healthcare expenditure in the USA. American healthcare spending grew about 4% in 2022 and accounted for a little over 17% of GDP.
Given such a large volume of expenditure for healthcare as well as adherence to state and federal guidelines, a dental practice must stay updated on healthcare compliance issues and manage such issues as required.
Compliance management also ensures that a practice offers high-quality care without wondering about imminent threats of any legal consequences that arise even when it comes to dental billing.
Failure to comply with regulatory guidelines or illegal billing can have a significant fallout for the practice. Despite these problems, one needs to examine the reasons behind dental billing fraud:
The dental team may use the wrong code or an incorrect patient ID at the time of billing. While such entries may not be termed as deliberate and have no benefit to the practice at large, there are negative implications that can arise.
The practice needs to ensure that there are regular training sessions for the billing team as well as mechanisms put in place to curtail the possibility of an accidental entry of data.
The obvious intention behind billing fraud can be assumed to be immediate financial gain. By using false data or incorrect codes that can yield higher financial outcomes, a dental practice can then get more money from insurance companies than what is due.
In a bid to drive patients or to reduce barriers to dental healthcare being expensive, a practice might misrepresent the procedures to aid the customer in gaining financial benefit. In such situations, both the practice and the patient are party to the commitment of fraud and bound by the consequences or negative effects of it.
It would be more beneficial for a dental practice to devise ways to reduce operational costs and pass this benefit to the customer. Additionally, effective promotional ideas can be deployed to attract more customers to the practice or raise the standards of patient care, and increase patient loyalty.
The legal implications of committing dental fraud are harsh. It can affect the reputation and financial stability of the practice. The extent and kind of fraud concerning dental
billing can erode the trust between the practice and the patient as well as violate regulatory laws and guidelines.
Getting caught in fraud causes severe reputational damage, and this can erode the trust of the patient in the practice. It will also hamper the acquisition of new patients and can also result in a loss of industry affiliations and professional partnerships.
If a practice has been implicated in fraud, it can be subject to greater scrutiny and audit from regulatory bodies or insurance organizations. Such additional scrutiny or inspections can lead to an impediment to regular business operations. It also creates additional stress for the dental team.
It is important for a practice to understand the types and impact of committing dental fraud while also maintaining ethical standards and avoiding legal consequences.
Fraud in billing can give rise to civil penalties. This can include fines and a return of monies that arise due to overpayment. As per FCA norms, penalties of up to three times can be levied based on damages suffered by the government. Many states also enforce civil penalties for billing fraud.
Practitioners guilty of fraud can be barred from participating in federal healthcare programs. Such exclusions can create a loss of income for the practice while even damaging its reputation.
Commitment to fraud in billing can lead to criminal penalties. As per FCA guidelines, submission of fraudulent claims to the government can lead to criminal conviction and imprisonment for up to 5 years.
Practices are also bound by state laws that can levy criminal penalties for dental billing fraud. The consequences can include fines, imprisonment, and a loss of a professional license. Dental practitioners that have been convicted would it tough to find employment in the industry. Moreover, it can be difficult to acquire a professional license again. Losing a license to establish a practice or offer services as a dental practitioner is a severely damaging outcome of fraud.
A guilty dental practice can face substantial fines imposed by regulatory bodies and might have to pay compensation to any affected party. If the amount is significant, it can severely impact the operational viability of the practice.
Dental billing fraud can have a financial implication for a patient. If a practice inflates bills and a patient does not have 100% coverage, then the balance amount will have to be borne by the patient. This is a bit risky for a patient when out-of-pocket expenses need to be paid upfront and then reimbursed later by the insurance company.
The impact of dental billing fraud is far greater than any temporary benefits that ca practice can gain. It not only erodes patient trust but can create a dent in the ecosystem. A practice needs to make sure that even a patient is protected from illegal dental billing practices.
