By Duane Tinker – The Toothcop
Let’s get something straight: most dental professionals aren’t trying to commit fraud. You’re not out there plotting how to cheat Medicaid or trick insurance companies. You’re just trying to run a practice, take care of your patients, and pay the bills. But here’s the uncomfortable truth: you don’t have to mean to commit healthcare fraud to be guilty of it. Perhaps you have heard the story of Dr. Roy Shelburne? He was NOT the only dentist to ever get busted for doing fraud – really.
I’ve spent years investigating healthcare fraud cases and helping dental teams clean up risky processes. And I can tell you—what you don’t know about healthcare fraud laws can absolutely hurt you, your license, your lifestyle, and your livelihood.
This isn’t about fear—it’s about being proactive. Let’s break down the healthcare fraud laws you need to know, the real risks they pose, and how to stay on the right side of the law without breaking a sweat.
Read this post carefully as I am about to throw down some SOLID recommendations. If you skim, you’ll miss them!
What Exactly Is Healthcare Fraud?
Healthcare fraud is when someone knowingly misrepresents or conceals information to get unauthorized payments from a healthcare program. In dental terms, that often means:
- Billing for services you didn’t provide
- Using the wrong CDT codes to bump up reimbursement (aka “upcoding”)
- Submitting claims for medically unnecessary treatment
- Falsifying dates or records
- Offering rewards for patient referrals
Even if it seems minor, if it results in a financial gain and violates the rules, it can be considered fraud. The worst part? Even unintentional mistakes can trigger investigations, civil and criminal penalties.
I’ve seen dental professionals disciplined, fined, and even criminally prosecuted over things they didn’t think were a big deal. Some had no idea they were doing anything wrong—until it was too late.
Why Should Dental Professionals Care?
Because dental practices are sitting ducks.
Medicaid programs, insurance companies, and state and federal agencies use data analytics to look for red flags—high volumes of certain codes, unusual billing patterns, excessive sedation cases, and so on. It’s all automated.
And it doesn’t stop there. Disgruntled former employees and even patients can file whistleblower reports and lawsuits. The stakes are high:
- Civil penalties of up to $28,619 per false claim
- Triple damages under the False Claims Act ($1 paid to you, $3 paid back by you)
- Exclusion from Medicaid and other programs
- Criminal charges in severe cases (hint: it’s not even about the dollar amount and no two cases are alike)
Not to mention reputational damage. Getting audited or investigated can turn your practice upside down—even if you’ve done nothing wrong.
The Big Four Laws You Need to Know
1. False Claims Act (FCA)
This federal and state laws make it illegal to knowingly submit false or fraudulent claims to government programs (like Medicaid). You’re on the hook not just for intentional fraud—but also for “reckless disregard” or “deliberate ignorance.” In a future post I’ll walk you through what this is (it’ll blow your mind).
🛑 Example: Billing for two quadrants of scaling and root planing when only one was treated that day? That’s a false claim.
2. Anti-Kickback Statute (AKS)
This prohibits offering, paying, soliciting, or receiving anything of value in exchange for patient referrals involving federal healthcare programs. This law is a criminal statute (fine and prison).
🛑 Example: Giving patients gift cards for referrals? That could be a kickback—even if you meant it as a thank-you. Back to school backpacks for the kiddos? Nope, can’t do that either!
3. Stark Law (Self-Referral Law)
This one’s about financial relationships. You can’t refer patients to services or entities you or your family have a financial interest in, unless very specific exceptions apply. This law is a civil statute (fine only).
🛑 Example: Referring patients to a lab or imaging center you co-own? You better have your ducks in a row.
4. HIPAA & Documentation Fraud
Altering patient records, backdating treatment, or leaving out crucial clinical details to support billing is both a HIPAA violation and fraud.
🛑 Example: Writing up a clinical note after the fact to match a claim? Dangerous territory. If you ever need to make a correction, copy and quote in a new note on the current date. Specify what was wrong in the previous note (in quotes) and write what ‘should’ have been documented.
Common Dental Fraud Triggers
Want to know what makes investigators come knocking? Here’s a short list of common red flags:
- Overuse of high-reimbursement codes (crowns, full quadrant SRPs, occlusal posterior fillings, sedation (type and time)
- Submitting multiple claims for the same patient visit (even by mistake) (don’t say it doesn’t happen in your office, it may and it may really surprise you)
- Excessive/inappropriate use of D1330 (OHI)
- Inconsistencies between documentation and billing dates (explain discrepancies)
THIS IS NOT AN EXHAUSTIVE LIST!
How to Protect Yourself and Your Practice
1. Train Your Team —Regularly.
If your staff doesn’t know the laws, they can’t follow them. Everyone—from your biller to your assistant—needs compliance training. No, doctor, you can’t skip training either.
2. Review What You’re Billing.
Run regular internal audits. Compare your notes to your claims. Ask, “Does this documentation support what we billed?”
3. Stop Coding Based on Insurance Coverage.
Only code what you did, not what you think will get paid. That’s a hard truth, but it’s critical. Taking a financial dig at the payor because their fees are low, because you placed a suture, broke a sweat, or it took a long time (actual excuses I hear) will only get you in trouble down the road.
4. Document Like a Lawyer’s Watching.
Because one might be. Even worse – they’re certainly being watching by other dentists who have their own clinical opinions. Think they won’t see through you? Your clinical records should be specific, complete, and honest.
5. Build a Written Compliance Plan.
This isn’t just for DSOs. Every practice—yes, even your teeny tiny little practice in the middle of nowhere—should have written policies, a reporting process, and annual training. Podunk dentists get busted, too!
Final Thoughts from The Toothcop
You became a dentist to do good and fix smiles – to improve the lives of others, not to stress about subpoenas or other regulatory/legal crap. But we can’t ignore the reality of how easy it is to cross legal lines without realizing it.
You don’t need to be perfect—but you do need to be aware (alert). If you are a good guy (or gal) you also have to ‘look’ like a good guy (or gal). Because ‘you are’ a good guy is no longer good enough. You have to tell people you are a good guy, your actions need to show that as well. There is nothing passive about protecting your good name and frankly, nobody else cares as much about your good name as you do.
Start by educating yourself and your team. Build compliance into your practice culture. And when in doubt or you get stuck, reach out. I’m here to help you avoid problems—not just fix them after the fact. I do that too and it’s REALLY expensive.
If you ever want a mock audit or need help building a rock-solid compliance program, you know where to find me. It’s what I do and while I loathe rules and regulations I LOVE working with dentists who care.
🦷 Stay sharp,
Duane Tinker — The Toothcop