12.2 Insurance Billing Ethics: Accurate Claims, Fees, Copayments, and Codes
Key Takeaways
ADA Advisory Opinion 5.B.2 says raising a fee because a patient has dental benefits is unethical overbilling.
Accepting an insurer's payment as payment in full while secretly waiving the patient's copayment is overbilling under ADA Advisory Opinion 5.B.1.
ADA Advisory Opinion 5.B.5 says misdescribing a procedure on a claim to get more payment, or to make a non-covered service look covered, is unethical.
California B&P § 810 makes knowingly presenting a false insurance claim unprofessional conduct, and a felony conviction for Medi-Cal (including Denti-Cal) or workers' compensation fraud is cause for automatic suspension.
CDA Code Advisory Opinion 7.A.3 requires refunding any payment received for a service that is never rendered, immediately.
Why billing is an ethics question (K2101)
Insurance fraud in dentistry rarely looks like a scheme. It usually starts as "helping" a patient. The ADA Code's principle of veracity and the CDA Code's Section 7 ("A dentist has the obligation to submit any billing for services rendered or to be rendered in a manner which is not fraudulent, deceitful, or misleading") treat the claim form as a statement of truth, whatever the motive.
The ADA advisory opinions on fees (Section 5.B)
| Opinion | Conduct | Why it is unethical |
|---|---|---|
| 5.B.1 Waiver of copayment | Accepting the insurer's payment as payment in full without telling the insurer the patient's share won't be collected | It makes the fee look higher than it really is, which is overbilling |
| 5.B.2 Overbilling | Raising a fee solely because the patient has benefits | Charges the insured patient more for the same service |
| 5.B.3 Fee differential | Defines the full fee as the fee for a patient without benefits; that fee is reported to all carriers regardless of negotiated discounts. Payments accepted under government programs or participating agreements are not evidence of overbilling | Sets the honest baseline |
| 5.B.4 Treatment dates | Reporting incorrect dates to get benefits | False representation (Section 12.1) |
| 5.B.5 Dental procedures | Misdescribing a procedure to get more payment, or making a non-covered procedure appear covered | False representation |
| 5.B.6 Unnecessary services | Recommending or performing unnecessary procedures, regardless of the practice arrangement or contract | Section 12.5 |
The CDA Code, Section 7, adds:
- 7.A.1: don't imply you are a provider for the patient's plan when you are not.
- 7.A.2: a copayment waiver without disclosure to the payer may be overbilling.
- 7.A.3: avoid billing for services not rendered. If payment is received for a service never provided, refund immediately.
California law on false claims
- B&P § 810(a): knowingly presenting, or causing to be presented, a false or fraudulent insurance claim, or preparing a writing to support one, is unprofessional conduct.
- § 810(b): conduct prohibited by Insurance Code § 1871.4 or Penal Code §§ 549–550 is grounds for revocation or suspension.
- § 810(c): a felony conviction for fraud in providing workers' compensation benefits, or for Medi-Cal fraud (including the Denti-Cal program), is cause for automatic suspension of a dental license, followed by a Board hearing on further discipline. More than one such conviction is cause for automatic suspension and revocation.
- Penal Code § 550(a)(6)–(7): knowingly making a false claim for a health care benefit, or submitting a claim for a benefit not used by or on behalf of the claimant, is a crime.
- B&P § 1680(a): obtaining any fee by fraud or misrepresentation is unprofessional conduct.
Common billing traps
| Scenario | Ethical answer |
|---|---|
| Crown prepared December 20 and seated January 5; the plan pays on completion, and benefits reset January 1 | Report the date the plan's rules and CDT define as completion. Don't backdate the seat or report the prep date as completion to capture the old year's benefit |
| Plan pays for a two-surface amalgam but not a composite; the dentist places a composite and bills the amalgam code | Misdescribing the procedure (5.B.5). Bill the composite; the plan may apply an alternate benefit, and the patient pays the difference if their contract allows |
| "Your insurance covers 80%, so we'll make our fee higher" | Overbilling (5.B.2) |
| Waiving a patient's 20% copay "as a courtesy" without telling the insurer | Overbilling (5.B.1). Disclose the discount, or reduce the fee reported |
| Billing a periodic exam that was not done because the patient left early | Billing for services not rendered: correct the claim or refund (CDA 7.A.3) |
| Coding scaling and root planing for a patient with healthy pockets to raise production | Unnecessary service (5.B.6) and false claim (§ 810) |
| Medi-Cal patient: billing the patient for the balance of a covered service | Unlawful balance billing (Welfare and Institutions Code § 14019.4) |
Other legitimate fee practices
- Discounts are allowed when honestly reported: B&P § 657 expressly lets providers discount for prompt payment and for uninsured patients.
- Contracted fees under participating agreements are not overbilling (5.B.3).
- Alternate-benefit provisions are the insurer's decision. The dentist codes what was actually done and explains the patient's share.
- Predeterminations give the patient cost information in advance (Section 7.4).
Worked scenario
A long-time patient loses her job. She asks the dentist to "just bill my husband's insurance for the cleaning you did on me," because his plan has benefits left.
- Billing a service under a person who did not receive it is a false claim for a benefit not used by the claimant (Penal Code § 550(a)(7)) and unprofessional conduct (B&P § 810).
- The ethical path is to explain honestly, offer a lawful discount for an uninsured patient (§ 657) or a payment plan, and document the conversation.
A dentist's fee for a crown is $1,200 for patients without insurance. When a patient with dental benefits needs the same crown, the dentist bills $1,400. Under the ADA Code, this is:
Acceptable, because insurers negotiate fees down
Overbilling, because increasing a fee solely because the patient has benefits is unethical
Acceptable, if the patient agrees in writing
Required, to cover the cost of filing claims
A dentist routinely tells insured patients, "Don't worry about your copay," and accepts the insurer's payment as payment in full without telling the insurer. What does the ADA Code call this?
A permitted courtesy discount
Fee splitting
Overbilling, because it misrepresents the actual fee to the third-party payer
A patient-selection decision under Section 4.A
Under B&P § 810, what happens to a dentist's license after a first felony conviction for Denti-Cal fraud?
It is cause for automatic suspension, and the Board holds a hearing on further discipline
Nothing, unless a patient files a complaint
It is placed on inactive status until renewal
The dentist must complete two units of ethics CE
Sections you finish are checked off in the contents.