The purpose of Delta Dental of Colorado’s Program Integrity department is to prevent, detect, and deter fraud and abuse.
Is it Fraud?Fraud is an intentional deception or misrepresentation of a fact that an individual or entity makes, knowing that the misrepresentation could result in an unauthorized benefit to the individual, entity or some other party.
Is it Abuse?Abuse is an intentional pattern of conduct that is inconsistent with sound, ethical, dental, business or fiscal practices and which could directly or indirectly result in unnecessary costs and/or payments.
Cost of FraudThe United States spends more than $2 trillion on healthcare annually. At least 3% of that – or $68 billion – is lost to fraud each year. Delta Dental takes fraud seriously, because it negatively impacts our subscribers. While it’s only a small percentage of providers or consumers who commit healthcare fraud, that small percentage can have a big impact.
You Can HelpHelp us fight fraud and abuse by recognizing signs of possible fraud and knowing how to report your suspicions. Providers can review claim forms prior to submission. Subscribers should review the Explanation of Benefits forms they receive from Delta Dental.
Examples of fraudulent practices:
- 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
- Individuals who use someone else’s identification card