1. Upcoding

Upcoding occurs when a dentist bills for a more expensive procedure than what was performed. This deceptive practice is one of the most common forms of dental fraud.

The most frequent examples include:

• Billing a surgical extraction when only a simple extraction was performed

• Charging for deep cleaning when only routine prophylaxis was provided

• Coding a comprehensive exam when only a limited evaluation was conducted

• Billing for a more complex restoration when a simpler one was done

Upcoding is illegal, as it constitutes a false claim that leads to insurance overpayment. This practice violates the False Claims Act and can result in severe penalties, including fines, license revocation, and criminal charges.

To avoid upcoding and protect your practice, use accurate chairside charting systems, run regular internal audits, train staff thoroughly on coding and billing, stay updated on current coding guidelines, and prioritize accuracy over maximizing profits.

2. Unbundling

Unbundling separates a procedure into parts and bills for each separately, resulting in higher total costs. The ADA considers this a serious ethical and legal violation.

Instead of billing for a comprehensive service under one code, unbundling inappropriately separates components like examinations, X-rays, cleaning, and oral hygiene instruction into individual charges.

This constitutes misrepresenting services for financial gain. The consequences include financial penalties, license suspension, exclusion from insurance networks, and reputational damage.

To prevent unbundling issues and avoid violations, you should understand CDT codes and bundling rules, run regular billing audits, thoroughly train all coding staff, and consult experts when uncertain about proper coding.

3. Billing for Services Not Rendered

This occurs when a dental practice submits claims for procedures never provided to patients.

Common examples include:

• Claiming fluoride treatments were given when they were not

• Billing for X-rays not taken

• Submitting claims for non-existent sealants

• Charging for periodontal treatments when only routine cleanings were provided

When a practice bills for services that were never provided, it directly violates the False Claims Act. This is easily detected during insurance audits and often triggers focused investigations, which result in severe penalties.

To protect your practice, incorporate multi-step verification before claim submission, complete clinical documentation before billing, regularly audit records against submitted claims, separate clinical and billing staff responsibilities, and establish clear documentation protocols.

4. Waiving Co-payments and Deductibles Unlawfully

Another illegal dental billing activity is routinely waiving patient co-payments or deductibles without proper documentation and notification to insurers, which constitutes fraud.

This practice misrepresents the actual cost of treatment to insurers. When you submit a claim showing the full fee but don't collect the patient portion, you're misleading the insurer about the actual charge.

There are some exceptions for genuine financial hardship cases. They may warrant fee waivers, but must be properly documented with:

• Clear criteria for qualifying

• Individual case evaluation

• Supporting documentation in patient files

Always report fee waivers to insurance providers. Be transparent, as hiding waivers transforms a legitimate accommodation into fraud. Follow insurers' specific procedures for reporting hardship waivers.

5. Misrepresenting Dates of Service

Misrepresentation involves deliberately altering treatment dates to fit within insurance coverage windows, exploiting the billing system to maximize reimbursement.

This typically involves changing documented procedure dates for financial reasons, confirming service coverage, or circumventing benefit limitations. Altering claim forms is an illegal dental billing mistake that insurers can detect with sophisticated software.

Misrepresenting dates constitutes falsification of medical records, a criminal offense with severe consequences:

• Substantial fines and penalties

• License suspension or revocation

• Exclusion from insurance networks

• Potential imprisonment

To prevent misrepresentation, use automatic timestamping systems, require same-day documentation, conduct regular internal audits, train staff on proper documentation, and establish clear policies about billing integrity.

6. Accepting Kickbacks for Referrals

Accepting kickbacks involves giving or receiving payments specifically for patient referrals, violating the federal Anti-Kickback Statute.

Penalties include:

• Criminal fines up to hundreds of thousands of dollars

• Imprisonment up to 5 years per violation

• Civil monetary penalties

• Exclusion from government programs

• License suspension or revocation

Instead, referral relationships should be built legitimately through clinical excellence, community involvement, professional organization participation, and positive patient experiences.

7. Overcharging or Phantom Billing

This involves billing for services never performed or deliberately inflating treatment costs.

Common cases include:

• Billing for multiple filling surfaces when only one was treated

• Charging for complete X-rays when only a few were taken

• Billing for premium materials when standard ones were used

• "Phantom billing" for treatments never performed

Repercussions for fraudulent billing are financial penalties and repayment, criminal charges, license suspension or revocation, insurance network exclusion, and irreparable reputational damage.

To maintain ethical standards and transparent billing, provide detailed, itemized invoices, confirm accurate coding, train staff regularly, incorporate internal auditing, document all treatments thoroughly, and clearly communicate fees to patients.

8. Double Billing

Double billing occurs when a practice submits the same claim multiple times, violating the False Claims Act.

Double billing can be:

• Accidental (clerical errors, miscommunication, software glitches)

• Intentional (deliberately submitting duplicate claims)

Remember that the law doesn't distinguish between mistakes and fraud when assessing penalties.

Double billing can result in heavy financial penalties, potential criminal charges, loss of provider credentials, reputational damage, and insurance network exclusion.

To prevent double billing, use software that flags potential duplicates, establish clear protocols for claim submission, thoroughly train administrative staff, conduct regular audits, and document insurance communications.

9. Providing Unnecessary Procedures

This involves performing and billing for treatments not clinically required, directly harming patients physically and financially.

This practice:

• Violates the "do no harm" principle

• Subjects patients to unnecessary risks

• Creates financial hardship

• Destroys trust in the dental profession

Performing unnecessary procedures to increase billing constitutes fraud, especially when targeting vulnerable populations. Cases involving unnecessary procedures on perfectly healthy teeth have resulted in criminal charges, massive penalties, and license revocation.

To avoid recommending unnecessary procedures, base recommendations on clinical evidence and standards, document thoroughly why procedures are necessary, get second opinions for complex treatments, follow conservative approaches when options exist, and educate patients about treatment necessity.

10. Misrepresenting Provider Information

Misrepresentation occurs when billing under the name of a different dentist than the one who performed the treatment, typically to boost reimbursement or hide credentialing issues.

This frequently happens when practices bill under a credentialed, in-network dentist when an out-of-network dentist performed the treatment. It's fraudulent because you receive funds you're not entitled to.

To avoid this issue:

• Verify all dentists are properly credentialed

• Update provider information promptly

• Submit claims only under the treating dentist's name

• Implement verification processes in billing workflows

Consequences include insurance audits, claim repayment, network termination, and potential fraud charges.

How to Protect Your Practice from Illegal Dental Billing Practices

Preventing billing violations starts with a proactive, well-informed approach across your entire team. Even minor oversights can escalate into serious issues if left unchecked. To minimize risk and maintain compliance, consider the following strategies:

Train Staff on Compliance and CDT Coding

Ongoing education is vital for staying compliant and running a legally sound practice. Invest in regular, structured training that covers the latest CDT code updates, proper code selection, insurance verification, claims processing, and HIPAA documentation standards. These aren’t one-and-done efforts; coding changes annually, and payer requirements can shift without much notice.

Encourage your team to stay current by following industry updates and reading the best dental blogs and trusted sources. The American Dental Association offers in-depth resources, webinars, and self-paced courses that help keep your staff updated and confident in their billing practices.

Perform Regular Internal Audits and Documentation Reviews

Routine internal audits are one of the most effective ways to catch errors before they become liabilities. Establish a consistent review process to cross-check clinical notes with billing records, confirm that services billed were actually rendered, and verify that CDT codes are used accurately based on supporting documentation. Look closely at EOBs, denied claims, and reimbursement trends; these can often point to deeper issues in your billing workflow. Audits also allow you to spot patterns that could flag your practice for external review, giving you time to correct the course before problems grow.

Work with Reliable Billing Consultants and Smart Software Tools

Partnering with experienced dental billing consultants or using purpose-built software can significantly reduce compliance risks. Choose practice management systems with built-in safeguards such as automatic coding prompts, real-time error detection, and audit trails to help spot inconsistencies before they become problems.

Specialized dental billing software can flag unusual billing patterns or discrepancies, helping your team stay aligned with payer requirements and documentation standards. If outsourcing, work only with consultants or services with a strong track record, verified credentials, and clear compliance-support protocols.

The use of AI for dental practice management is becoming increasingly valuable. AI can streamline coding, identify trends in denied claims, and help maintain billing accuracy while reducing the administrative burden on your team.

Foster a Culture of Transparency and Accountability

Creating a workplace culture rooted in integrity is one of the strongest defenses against illegal billing. Establish clear, written anti-fraud policies and standardized procedures for reporting and resolving billing discrepancies. Offer anonymous reporting channels and lead by example with ethical decision-making at every level of your practice.

Transparent financial policies and systems, like offering in-house membership plans with clear pricing or dental payment programs, can further build patient trust while minimizing the risk of billing confusion. When your team understands that accuracy and accountability are priorities, compliance becomes a shared responsibility, not just a top-down directive.

Hire With Integrity in Mind

Your dental practice’s reputation is built on trust, professionalism, and ethical care. Partnering with hygienists who share those values is essential, not just for compliance, but for delivering the high-quality patient experience your office is known for.

At Teero, we connect dental offices with skilled, vetted hygienists for both temporary coverage and permanent placements. Whether you need someone to fill in during a team member’s leave or you're expanding your team long-term, we make it easy to find professionals who align with your standards.

Let’s work together to keep your practice running smoothly. Give us a call to get started.

Disclaimer: The information provided in this article is for general informational purposes only and does not constitute legal advice. You should consult a qualified legal professional for advice on specific legal issues.