By Duane Tinker – The Toothcop
Dental Compliance Consultant | Former Investigator | Trusted Advocate for Ethical Dentistry
What Every Dentist Should Know About the False Claims Act
You may think the False Claims Act (FCA) only applies to hospitals or big medical providers.
But if you bill Medicaid, CHIP, or any federal healthcare program, your dental practice is squarely in its crosshairs.
I’m Duane Tinker—The Toothcop. I’ve investigated False Claims Act violations and helped dental teams recover from them. This law is powerful, complicated, and—if you’re not careful—dangerous.
In this post, I’ll walk you through what the False Claims Act is, what it looks like in a dental setting, and how to avoid making a mistake that could cost you your license (or worse).
What Is the False Claims Act?
The False Claims Act (31 U.S.C. §§ 3729 – 3733) is a federal law that prohibits:
“Knowingly submitting false or fraudulent claims for payment to the U.S. government.”
This includes:
• Billing for services not rendered
• Overcharging for services
• Upcoding procedures
• Using unlicensed staff to perform billable procedures
• Falsifying documentation
• Retaining overpayments and failing to refund
• Improperly certifying medical necessity
Violators can face:
• Civil penalties of up to $27,000 per false claim
• Treble damages (3x the amount defrauded)
• Exclusion from Medicaid/Medicare
• Whistleblower lawsuits (qui tam actions)
Key Concept: “Knowingly” Doesn’t Mean “Intentionally”
You don’t have to commit fraud on purpose to violate the FCA.
Under the law, “knowingly” includes:
• Actual knowledge
• Deliberate ignorance
• Reckless disregard
If you “should have known” a claim was false and billed it anyway, you’re still liable.
This is why sloppy documentation, bad delegation, and ignoring coding rules can land you in deep trouble—even if you didn’t mean to do anything wrong.
What Does a False Claim Look Like in Dentistry?
Real-world examples:
1. Billing for a full-mouth debridement (D4355) and prophy (D1110) on the same day
– Not typically allowed, unless justified
2. Upcoding a simple extraction (D7140) as a surgical one (D7210)
– Higher fee, but unsupported/justified/warranted
3. Using a dentist’s NPI to bill for work done by an unlicensed assistant or even work done by another licensed dentist (wrong provider NPI)
– Fraudulent substitution
4. Billing for x-rays that were never taken
– Easy to detect with chart reviews
5. Failing to refund overpayments after a pre-payment audit finds errors
– Violates the “reverse false claims” provision
What Triggers False Claims Act Investigations?
• Whistleblowers (often employees)
• Medicaid Managed Care Organization (MCO) referrals
• Data analytics revealing abnormal billing trends
• Complaints from patients or guardians
• Previous audits or sanctions
Remember, whistleblowers can file qui tam lawsuits and share in the recovery. That’s a major motivator for former employees to speak up.
How to Protect Your Practice
1. Implement a Robust Compliance Program
Your program should include:
• Billing and coding training
• Regular audits
• Policies on refunds and overpayments
• A reporting hotline for staff concerns
• Written procedures for proper documentation
2. Audit Regularly
Conduct quarterly internal audits or bring in a professional. Review:
• Coding accuracy
• Documentation support
• Provider attribution
• Signature/date accuracy
3. Train and Retrain Your Team
Focus on:
• Common FCA red flags
• What counts as “fraud”
• When to escalate concerns
Make sure everyone from front desk to RDHs understands what’s at stake.
4. Fix Problems Promptly
Find an error? Own it, fix it, and self-report if necessary. Cover-ups get prosecuted harder than mistakes.
5. Document Everything
If it’s not in writing, it didn’t happen. If it’s in writing and wrong, you’d better explain it.
The Toothcop’s Take
False Claims Act violations don’t just cost money—they end careers.
Most FCA trouble I seen in dentistry isn’t about greed. It’s about negligence.
Poor recordkeeping. Missing notes. Letting staff do things they’re not qualified to do (includes lapse of license/registration). Not refunding known overpayments.
It’s all preventable.
Stay sharp