Quick answer. Insurers and regulators treat these as improper billing: charging for work not completed, billing a higher code than the work done, splitting one procedure into several codes, routinely skipping the patient share while billing the full fee, and reporting a wrong date or provider. Each leaves a trace in the ledger. This page is not legal advice, and a flagged row is a reason to look, not a finding.
An insurer sends a records request. Six crowns billed in one month on one provider, and the notes support four. The other two were planned, and the claims went out anyway. That is the situation this page is for: what counts as improper, what a pattern looks like in your own data, and what to do next.
This page is not legal advice. It describes how insurers and regulators talk about billing. If something looks wrong in your practice, call your attorney.
What counts as an illegal dental billing practice?
Anything that misstates, to a payer, what was done, when, by whom or what you charge for it, in order to be paid more or to be paid at all. Delta Dental puts the line at intent: fraud needs deliberate deception for gain, and an unintended error is negligence (Delta Dental, “5 common billing practices that may be fraud”, 8 Aug 2022). The software cannot see intent. It can show repetition, timing and who was logged in. So the useful question is not “who is cheating” but “which rows repeat, and why”.
What do insurers and regulators say?
| Source | What it says | Date |
|---|---|---|
| Delta Dental | Five practices that may be fraud: services not performed, waived deductibles or copayments, altered dates of service, claims under another member, unbundling | 8 Aug 2022 |
| ADA Code of Ethics, 5.B | Fees must not be represented in a false or misleading manner. Advisory opinions cover waiver of copayment (5.B.1), treatment dates (5.B.4), procedure descriptions (5.B.5) and unnecessary services (5.B.6) | Advisory opinions revised Oct 2024 |
| HHS-OIG, Texas dentists settlement | $3.1 million to resolve False Claims Act allegations of pediatric dental services billed but not rendered, or billed under the wrong provider | 14 May 2021 |
| HHS-OIG, MB2 Dental settlement | $8.45 million to resolve allegations of Medicaid claims for services not rendered, kickback-tainted or naming the wrong provider | 9 Jan 2017 |
| US Attorney, W.D. Kentucky | $5.1 million over allegations of simple extractions billed as surgical and scaling and root planing billed when not performed or not necessary. No admission of wrongdoing | 6 Nov 2018 |
These are allegations that were settled, not findings of guilt, and the large ones are Medicaid cases. Commercial plans enforce through contracts, audits and recoupment, and state insurance fraud laws apply as well.
What are the common patterns, and how do they look in the ledger?
Reading this table. A match is a reason to open the chart, never a conclusion. Most rows turn out to be training problems or legitimate exceptions.
| Pattern | What it means | What the data can show |
|---|---|---|
| Billing for services not rendered | A claim for work that was planned, started or never done | Claims with a completed procedure but no chart note or image on the same date; claims on a date the patient had no appointment |
| Upcoding | A higher-fee code than the work supports | Surgical extraction or perio codes that are far above the practice’s own mix; one provider with a mix unlike the others |
| Unbundling | One procedure split into component codes | Two or more codes for the same tooth and date that the plan treats as one |
| Routine copay or deductible waivers | Billing the full fee, not collecting the patient share | Courtesy adjustments on most in-network claims; patient portion written off with no account note |
| Wrong dates | A date that moves a claim into a benefit year or past a waiting period | Procedure date differing from appointment date; claims submitted before the visit |
| Wrong provider | Work billed under a provider who did not do it | Procedures by hygienists or associates carried under another NPI where the plan does not allow it |
| Claim under another patient | Treating one person, billing another | Same procedure on two family members on one date with only one appointment |
| Duplicate billing | The same service billed twice, or to patient and insurer both | Two claims for the same procedure and tooth; a patient paid and the insurer also paid, leaving a credit |
| Unnecessary services | Recommending or doing work the findings do not support | Not visible in the ledger. This needs clinical review (ADA 5.B.6) |
The date rule in plain terms
A multi-visit procedure is complete on its last step. Delta Dental of New Jersey says the completion date for crowns, onlays and inlays is the cementation date, and for root canal therapy the date the canals are permanently filled (Delta Dental of New Jersey, 2018). Bill on the preparation date and you have a pattern a payer can see. The ADA treats reporting incorrect dates to help a patient obtain benefits as a false or misleading representation (5.B.4).
The waiver rule in plain terms
The ADA says a dentist who accepts a copayment-plan payment as payment in full, without telling the insurer the patient share will not be collected, is overbilling, because the claim makes the charge look higher than it is (5.B.1). Delta Dental takes the same position even when the patient asks.
What should I run in Open Dental, Dentrix and Eaglesoft?
Run each report for the last 90 days and write down what a normal month looks like before you judge any single row. The reports below are named at report level. Menu paths vary by version.
Procedures against chart notes. List completed procedures by date, provider and code, then match them to clinical notes.
- Open Dental: the procedure log and the Procedures Not Billed to Insurance report, plus the Audit Trail for changes after entry.
- Dentrix: Day Sheet and Procedure Log by provider, with the Audit Trail Reports.
- Eaglesoft: Day Sheet and Production by Provider, with the audit utility.
Adjustments by type and by user. Split contractual write-offs from courtesy or other adjustments. Share of non-contractual adjustments by user is the figure to watch. The write-off report page covers how to read it.
- Open Dental: Adjustments report.
- Dentrix: Adjustment report.
- Eaglesoft: Adjustments report.
Procedure date against appointment date. Look for claims whose procedure date has no matching appointment.
- All three: compare the Day Sheet or the claims history with the appointment book for the same period.
Duplicates and credits. Accounts with credit balances older than 60 days, and two claims for one procedure and tooth.
- Open Dental, Dentrix and Eaglesoft: the aging report with credit balances, plus claim history by patient.
What do I do if I find one?
- Do not change anything. Editing the record, changing permissions or confronting someone first can destroy the evidence you need and make a training problem look like something else.
- Preserve the audit log. Export it or take a copy before anyone is aware of the review.
- Read the whole story. For each odd row, read the full account ledger, the chart note and the appointment history.
- Separate error from pattern. One wrong code is correctable. The same mistake across months and across payers needs a different conversation.
- Call your attorney. They will tell you whether to correct and refund claims, whether to notify the payer, and how to speak to staff. Your malpractice carrier may also need to know.
If you already know a claim was wrong, ask your attorney about refunding the payer. Delta Dental runs an Anti-Fraud Hotline at 800-526-1852 for reports, and says you can stay anonymous.
How does a private audit trail help?
A ledger shows the state today. An audit trail shows what changed, when, and by which login, with the before and after value. That is the difference between “this adjustment exists” and “this adjustment was entered on the 3rd by this user, after the claim was paid”.
Calibic’s Protect module (LIVE) keeps a private, read-only, time-stamped copy of payment and adjustment changes from Open Dental, Dentrix and Eaglesoft, and raises alerts on a small set of patterns, such as a deleted payment or a courtesy adjustment on a paid account. See also what is dental fraud and deleted payments. It never writes to the practice software. It does not read clinical notes or images, so it cannot say whether treatment was necessary, and it does not decide who is at fault. A copy held outside the practice software is harder to alter quietly, which is its value when a payer asks for records.
What to do next
Pick one pattern from the table, run its report for the last 90 days and read the five least normal rows in full. If you want a time-stamped record to work from, see Protect.