Five Illegal Dental Billing Practices to Avoid

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Five Illegal Dental Billing Practices to Avoid

Are you worried you could be implementing illegal dental billing practices? Navigating the complex waters of dental billing can be as tricky as, well, a root canal without anesthetic. For most practitioners and office managers, the overarching goal is simple – to provide top-notch care while staying afloat in the sea of operational costs. But there’s the rub; in an industry as regulated as healthcare, billing cannot be overlooked, lest you risk sinking your entire operation due to non-compliant practices.


Billing in the dental world is a linguistic dance between the art of medicine and the science of getting paid. The tunes of compliance serenade you from every direction. It’s not melodious—more staccato—but it must be heard and obeyed, like a drill in a silent office.

In this comprehensive guide, we’ll highlight not-so-secret, but often misunderstood, illegal billing practices in dentistry. It’s crucial to keep your billing practices squeaky clean to protect your professional reputation and, frankly, your livelihood.

Upcoding: Proceed with Caution – Illegal Dental Billing Practices

Upcoding is the highway robbery of the dental world, demanding more compensation than you actually deserve. Similar to billing for a more complicated dental procedure than was actually done, such as charging for a root canal rather than a simple filling, upcoding brings in hefty fines and a loss of trust with patients and insurers.

An Example of Upcoding:

A patient comes in for a standard cleaning. Without explanation or need, they find that their provider has billed the procedure as a more involved, and consequently more expensive, periodontal maintenance.

The Legal Consequences

Legal repercussions for upcoding can include hefty fines, recoupment of wrongly-claimed funds, and in extreme cases, imprisonment. It’s a risk that’s not worth taking.

Unbundling: The Path to Disintegration -Illegal Dental Billing Practices

Unbundling treatments may seem like just another Tuesday at the office, but it’s akin to pirating in the billing universe, and it doesn’t just sink your ship—it erodes the trust of the entire fleet of insurance providers. Unbundling is breaking down a procedure into its individual elements to bill them separately. Not only is it deceitful, but it can also create a misrepresentation of the services rendered, a federal offense in the United States.

The Patient and the Puzzle Pieces

For instance, you perform a tooth extraction. Instead of billing for the simple extraction, you unbundle it, charging for the anesthesia, the actual extraction, the sutures, and any pain management prescribed afterwards as separate procedures.

Insurance Providers Under Threat

Unbundling tactics can lead to civil fines, exclusion from government programs like Medicaid, and yes, even criminal investigations.

Balance Billing: The Legal Quagmire – Illegal Dental Billing Practices

Balance billing is not black or white; there’s a murky gray area that has left many dental offices questioning their billing efficacy. It’s not inherently illegal but can be—like practicing in the dark, you’re bound to hit something unpleasant.

Navigating Out-of-Network Services

For example, a patient’s insurer underpays for a service because you’re out-of-network. You decide to bill the patient for the remaining balance, also called “extra-billing.”

Legality Varies

Legality of balance billing really depends on the service and the insurance plan. It can be legal, but it’s crucial to do your due diligence and communicate clearly with your patients about potential out-of-pocket expenses.

False Claims: The Sinister Subterfuge – Illegal Dental Billing Practices

Submitting false claims is playing with fire, with a near guarantee that you’ll get burned. This entails billing for services not rendered, commonly known as “phantom billing,” or billing for a more expensive service when a cheaper alternative was done.

The Anatomy of a False Claim

For instance, you bill for a full set of dentures when only a partial set was provided, or when no dentures at all were made for a patient.

Fines, Fraud, and Fury

The False Claims Act and other state laws provide severe penalties for fraudulent billing practices, both civil and criminal, including imprisonment and significant monetary penalties.

Phantom Billing: The Unseen Offense – Illegal Dental Billing Practices

Phantom billing, as the name suggests, is billing for services or items that were not provided. It’s the most literal embodiment of “money for nothing” and is unequivocally illegal.

The Act of Not-Doing

Say a patient leaves your office, healthy and satisfied, yet their invoice tells a different story. Services are billed that the patient never received, often under the guise of administrative errors or coding misinterpretations.

Disappearing into the Legal System

Phantom billing cases can result in jail time, exclusion from insurance programs, and the demand of repayment to patients and authorities.

Drop the PPOs! Start a Membership Plan

Working with PPOs comes with a host of challenges, mostly in the form of compliance headaches. Enter dental membership plans, a friendlier, more controllable alternative. These plans allow you to bill patients directly, avoiding the PPO contract-negotiation labyrinths and ensuring compliance is within your grasp.

The Beauty of Simplicity

Membership plans eliminate the need for complicated fee schedules, deductibles, and waiting periods.

Compliance Made Easy

By billing patients directly, you have complete control over your billing practices and can ensure compliance with regulations.

The Strategic Advantage of BoomCloud for Your Practice

BoomCloud emerges as an indispensable ally for dental practices aiming to transcend traditional billing constraints and forge a path toward financial autonomy. This platform ingeniously unlocks the potential of dental membership plans, offering an operational game-changer for dentists overwhelmed by the complexities of insurance dependency.

Direct Control Over Revenue Streams

By integrating BoomCloud into your practice, you seize direct control over your revenue streams, liberating yourself from the unpredictability of insurance reimbursements. This control not only stabilizes your income but also enhances predictability in your business forecasts.

Enhanced Patient Loyalty

BoomCloud champions patient loyalty by simplifying access to dental care through straightforward, transparent membership plans. This clarity and ease foster a stronger, more trustful patient-provider relationship, encouraging continued engagement and loyalty to your practice.

Operational Efficiency

Furthermore, BoomCloud’s platform streamlines administrative duties, significantly reducing the time and resources spent on billing and insurance negotiations. This efficiency allows your team to focus on what truly matters—delivering exceptional dental care.

Data-Driven Decisions

Armed with comprehensive analytics and reporting tools, BoomCloud equips practices with the insights needed to make informed, strategic decisions. Understanding patient enrollment trends, utilization rates, and financial performance becomes effortless, empowering practices to adapt and thrive.

In conclusion, adopting BoomCloud translates to cultivating a healthier practice-patient relationship, achieving operational excellence, and securing a dependable revenue model. For any dental practice aiming to modernize its approach and foster growth, BoomCloud is not just a tool; it’s a strategic advantage. Join the BoomCloud family and start reaping the benefits today.

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The BoomCloud™ Platform helps practices create & grow patient membership plans! Practices that grow their membership plan generate predictable recurring revenue, reduce dependence on PPOs & increase case acceptence by 3X. Build a better practice with your own membership program!

dental membership software


To wrap it up, the moral of the story is clear—when it comes to dental billing, compliance is paramount. These illegal billing practices may seem enticing with their promise of boosted revenue, but the risks far outweigh the benefits. It’s not just about avoiding legal trouble; it’s about maintaining the integrity of your practice and the trust of your patients.

Being on the right side of the law isn’t always glamourous, but it’s a surefire way to build a long-lasting, ethical, and successful dental practice. Now that you’ve brushed up on billing do’s and don’ts, it’s time to maintain a keen eye on your practice’s financial pulse. Compliant billing doesn’t just keep you out of hot water; it’s a grand display of professionalism that every patient deserves.

Key Resources for Dental Billing Compliance

ADA’s Comprehensive Guide to Dental Billing

The American Dental Association (ADA) offers an extensive range of resources aimed at helping dental practices ensure billing compliance and avoid the pitfalls of incorrect coding. Their comprehensive guide is a must-read for every dental professional striving for excellence in billing practices.

ADA Guide to Dental Billing

Dental Billing Compliance Webinars

Stay ahead of the curve with ongoing education. DentalBilling.com provides a series of webinars that cover the latest in dental billing practices, compliance issues, and how to avoid common billing errors. These webinars are an invaluable resource for continuous improvement and staying informed about the evolving landscape of dental billing.

DentalBilling.com Webinars

Download "The Million Dollar Membership Plan" E-book!

Learn tactics and strategies from practices that have built a million dollars in recurring revenue from their membership subscriptions alone! Creating a patient membership plan is the smartest strategy to implment in your practice. You will increase patient satisfaction & loyalty, Increase predictable recurring revenue & improve your case acceptence by 3X with members. Download the book Now!