Bridging the data gap between medical and dental claims
What fraud, waste, and abuse concerns are common to dental claims?
The increased coverage and spend for dental services by health plans and health agencies will expand the opportunity for fraud, waste, and abuse [FWA] within their dental claims data. When a plan or agency is solely reviewing their dental claims and single-provider bills for inappropriately submitted or paid claims, there are several scenarios that are commons aspects of potential FWA to assess:
- Diagnosis code manipulation: Justifying unnecessary procedures by applying a false or misrepresentative diagnosis code for the purpose of garnering higher insurance payments
- Repetitive services per tooth: Billing for multiple or repetitive services per tooth, such as extractions or implants for the same tooth number
- Services not rendered: Submitting claims with CDT codes that were never performed
- Unbundling: Billing for multiple CDT codes that should be billed under a single CDT code, which results in higher costs for the health plan or health agency as well as the patient or member
- Unlikely services: Submitting claims for tooth numbers that are unexpected based on the patient’s age
- Upcoding: Submitting the most expensive or comprehensive CDT code than the dental service provided
While the above scenarios can be identified solely within the dental claims data and dental records, the growth of dental revenue stream consulting groups that promote the practice of billing dental claims to medical insurance can impact the spend of a health plan or agency and contribute to inappropriately paid claims. As such, health plans and health agencies should consider cross-coding and multi-claim scenarios when reviewing a dental provider or practice to identify potential overpayments and inappropriately submitted or paid claims. Moreover, depending on how the dental claims are managed and paid, health plans and health agencies should consider dental-to-medical edits to reduce leakage and potential overpayments.
When can a dental provider bill a patient’s medical insurance?
Health plans and health agencies may allow cross-coding and billing of dental procedures to the patient’s medical insurance, which is dependent on the coverage as well as the services provided to the patient or member. Examples of cross-coding where dental services that might be covered by medical insurance include the following:
- Diagnostic exams to pinpoint pain or infections, such as panoramic dental x-rays and cone-beam computed tomography [CBCT]
- Medical insurance may cover treatment for mouth trauma and dental injuries, which will likely require a medical diagnosis
- Surgical procedures for extractions, removals, implants and biopsies, and preventive procedures might be considered for reimbursement by medical insurance.
- Cancer treatments may be delayed due to the medical necessity of an oral health exam, which may prompt medical coverage of the dental service.
- Some medical conditions and treatments may require non-surgical services, such as sleep apnea where an oral appliance is ordered for the patient.
What are examples of cross-coding duplicates?
When the provider submits different procedure codes on a dental and on a medical claim that represent the same or similar service, then the potential for an overpayment occurs as a cross-coding scenario. Numerous CDT codes and CPT or HCPCS codes represent the same or similar services and below are a few examples.
- Evaluation and management codes: CDT D0140 and CPT 99202 to 99215
- Panoramic x-rays: CDT D0330 and CPT 70355
- Alveoloplasty: CDT D7310 or CDT D7311 and CPT 41874
Examples of cross-coding duplicate scenarios that may appear in your health plan or health agencies claims data are in table 1.
Table 1: Examples of potential cross-coding duplicates
| Patient or Member | Group ID | Claim Type | Service Date | Procedure | Units | Tooth # |
|---|---|---|---|---|---|---|
| ABC00000001 | 123456 | Dental | 02/28/2025 | D0140 | 1 | N/A |
| ABC00000001 | 123456 | Medical | 02/28/2025 | 99203 | 1 | N/A |
| ABC00000002 | 234567 | Dental | 03/02/2025 | D0330 | 1 | UL |
| ABC00000002 | 234567 | Medical | 03/02/2025 | 70355 | 1 | N/A |
| ABC00000003 | 345678 | Dental | 01/30/2025 | D7311 | 1 | 32 |
| ABC00000003 | 345678 | Medical | 01/30/2025 | 41874 | 1 | N/A |
What are examples of multi-claim duplicates?
When a provider submits the same procedure code on a dental claim and on a medical claim, then the potential for an overpayment as a multi-claim duplicate exists, which is not as common as cross-coding. If the same provider submitted four dental claim lines for D7240 [Impacted tooth – completely bony] with four different tooth numbers and then submitted one medical claim with four units of service with D7240 as the procedure code, the medical claim lines could be duplicative. Due to the differences in required elements and representative values between dental claims and medical claims, such as tooth numbers, diagnosis codes, and units of service, analysis and identification of any potential multi-claim duplicates is based on a near-duplicates concept.
Examples of multi-claim duplicate scenarios that may appear in your health plan or health agencies claims data are in table 2.
Table 2: Examples of potential multi-claim duplicates
| Patient or Member | Group ID | Claim Type | Service Date | Procedure | Units | Tooth # |
|---|---|---|---|---|---|---|
| ABC00000001 | 123456 | Dental | 2/28/2025 | D7240 | 1 | 01 |
| ABC00000001 | 123456 | Dental | 2/28/2025 | D7240 | 1 | 16 |
| ABC00000001 | 123456 | Dental | 2/28/2025 | D7240 | 1 | 17 |
| ABC00000001 | 123456 | Dental | 2/28/2025 | D7240 | 1 | 32 |
| ABC00000001 | 123456 | Medical | 2/28/2025 | D7240 | 4 | N/A |
How can Codoxo assist your health plan or agency with identifying dental FWA?
When a health plan or health agency provides professional claims data and dental claims data to Codoxo, we ingest those claims by their distinct service type; however, we bridge the data gap at the provider and patient level so the users can view those services seamlessly in provider and patient profiles. Additionally, Fraud Scope’s detection models, such as Duplicates and Medical-Dental Cross Duplicates, can identify potential overpayments within the dental and medical claims for the health plan or agency.
Fraud Scope’s Query Builder with the All Medical option empowers users to combine and explore professional, facility, and dental intelligence at the line or claim levels and to define criteria specific to their assessment. Codoxo’s partners can apply groups of similar procedure codes to build line level queries to identify patients whose utilization history demonstrates duplicative or similar services by the same or different providers.
References:
Centers for Medicare and Medicaid Services – Medical Dental Coverage
Medicare Dental Coverage | CMS
ADA – Preventing Fraud and Abuse
Delta Dental – Dental Insurance 101 – Oral surgery coverage questions