One medical insurance benefit vulnerable to misuse by providers (and beneficiaries) is the dental plan. The alarming effects of this are not just seen in insurers' loss ratios but also in long-term dental costs, and the policyholder's health and wellbeing, says Dr Moona Menezes, dentist and medical claims benefits specialist at Aetna International.
Dental fraud schemes
She outlines several dental fraud schemes:
Based on her research, there are a few common dental fraud schemes that one should look out for. It is worth pointing out that some are solely the providers’ doing while some require involvement of the beneficiary.
Unnecessary services: The dentist can carry out treatments that are not clinically required; order excessive X-rays/scans; opt for treatments that are more invasive or choose to hurry treatments in order to reach dental insurance limits.
Pre-treatment billing: Most insurers require dental treatment, on direct billing, to be pre-authorised. Dental providers may obtain the approval from the payer for multiple services and schedule these to be completed during subsequent appointments. However, if they furnish bills for this prior to completion of the treatment, the policyholder would have lost a portion of their limit even if they choose not to complete the pre-approved treatment.
Un-bundling: Most providers will have a unified agreed rate for services that typically take multiple sittings to complete. However, in many cases, the dentist may charge for each sitting separately, inflating the overall cost of the treatment and consequently over-utilising your dental benefits.
Phantom billing: This is essentially where the provider bills for services that never took place. These may be reflected as additional services added to an actual bill or as entirely fabricated bills.
Identity theft: In this scenario, the provider will treat another individual but bill the services under another person's insurance plan. In many cases, the beneficiary is found to be involved in this practice, wherein a non-covered family member or friend is the recipient of the treatment.
Misrepresenting services: Some dentists might misrepresent cosmetic or non-covered services, when submitting the bill, to get these covered. This is another case where the beneficiary may or may not be involved in the fraud.
Impact of fraud
Depending on the specific case, dental fraud can have an adverse effect on the policyholder's health (eg. Overexposure to radiation), dental coverage and in certain instances, even result in legal action against the policyholder.
As an indication of the losses due to medical fraud (including dental), according to one recent report, abuse of health services in the UAE cost 10-15% of total collected premiums.