Delta Dental of South Dakota (Delta Dental) is committed to conducting business in an ethical manner which includes preventing, detecting and mitigating potential fraud and abuse. Our commitment requires the help of our subscribers, providers, and employees to identify potential violations.
Cost of Fraud
According to the National Health Care Anti-Fraud Association, of the $250 billion spent on dental care procedures annually nationwide, an estimated $12.5 billion, or 5%, is lost to dental fraud and abuse. Loss to fraud and abuse can increase everyone’s costs for coverage and care.
What is Fraud?
The intentional deception or misrepresentation made by a person for profit or to gain an unfair advantage.
What is Abuse?
A pattern of conduct that is inconsistent with fair, ethical, dental, business or fiscal practices and which could result in unnecessary costs and/or payments.
Examples of Potential Fraud & Abuse
- Billing for services not rendered;
- Billing for a service that is covered, when a non-covered service was performed, in order to gain payment;
- Altering service or treatment in claims submission to obtain benefit payment for a different, more expensive, treatment;
- Altering the date of service to fall within member’s eligibility;
- Concealing other insurance coverage; or
- Using someone else’s identification card.
You Can Help
As a patient you can:
- Treat your Delta Dental insurance card like a credit card. Don’t let anyone borrow your card. If it is lost or stolen contact customer service at 877-841-1478.
- Protect yourself from identity theft.
- Look carefully at each Explanation of Benefits (EOB) you receive.
- After you’ve visited a dental office an EOB is issued informing you what has been billed.
- Make sure you had the visit or service on the date stated on the EOB. If it doesn’t seem right, call the dental office and ask them to explain it to you. If you would like help in reading your EOB, please call Delta Dental customer service at 877-841-1478.
As a dental office you can:
- Review your claim forms prior to submission, making sure the treatment in the patient’s clinical notes is accurately reflected on the claim.
- Make sure the dentist listed on the claim as the treating dentist is the one who actually performed the services.
- Disclose all discounts or waivers of any co-payment.
- Accurately file claims. Do not alter dates of services or file misleading treatment to maximize a patient’s benefits.
Suspect Fraud? Report it!
Contact us immediately if you suspect fraud or abuse. You may remain anonymous or share your contact information. We will do our best to protect your confidentiality and protect you against retaliation. Please provide a detailed account of the situation so we can fully investigate your report.