Health News with Steven and Mady - Health Insurance Fraud with Dentists and Double-Dipping

Ever looked at a dental bill and wondered how a routine cleaning turned into a tangle of codes and surprise charges? We dig into the hidden world of dental insurance fraud—upcoding, unbundling, phantom billing, and double charging—and explain how these tactics quietly raise your costs and erode trust. Drawing from a first-hand story about a $26 “gingival rinse” that was just tap water, we unpack the excuses patients often hear, like “the insurance made us code it this way,” and show you how to separate fact from fiction.

We walk through specific red flags on invoices and Explanations of Benefits, from duplicate entries to premium materials you never received. You’ll learn how to request the exact CDT codes your dentist plans to bill, use predeterminations to get clarity before treatment, and compare claim submissions to your EOB line-by-line. For listeners in Texas, we outline the concrete steps and hotlines for reporting suspected fraud to the Texas State Board of Dental Examiners, the Texas Department of Insurance Fraud Unit, and the Health and Human Services OIG for Medicaid or CHIP. We also share what to include in a complaint so investigators can act quickly.

Most importantly, we focus on protection: choosing in-network dentists to reduce balance billing risk, asking for written estimates, getting second opinions for non-emergencies, and keeping thorough documentation. We even role-play a surprise bill scenario so you can hear how to push back with confidence and professionalism. Knowledge really is power—use it to keep your care honest and your costs fair.

If this helped, follow the show, leave a quick review, and share the episode with someone dealing with a confusing dental bill. Your story could help another listener spot a red flag and save real money.

• Texas Department of Insurance (TDI) — reporting insurance fraud
   
  • Fraud Hotline: 1-800-252-3439Texas Department of Insurance+3Texas Department of Insurance+3Texas Department of Insurance+3 
• Alternate toll free: 1-888-327-8818 (shown on fraud report form) CloudFront 
• Email for suspected fraud: FraudReport@tdi.texas.govTexas Department of Insurance 
• Texas State Board of Dental Examiners (TSBDE) — for complaints about dentists
   
  • Complaints email: complaints@tsbde.texas.govTexas State Board of Dental Examiners 
• Fax: 512-649-2732 Texas State Board of Dental Examiners 
• Phone (fraud / investigations): (512) 936-9500 Texas State Board of Dental Examiners 
• Texas HHSC / OIG (Medicaid / provider fraud)
   
  • Fraud Hotline: 1-800-436-6184

Chapters

• 0:00 Cold Open & Sea Shanty Intro
• 1:05 Setting The Topic: Dental Fraud
• 1:46 Disclaimer & Purpose
• 2:18 What Counts as Dental Insurance Fraud
• 3:10 Upcoding, Unbundling, and Phantom Billing
• 5:39 Why “Blame the Insurance” Is Misleading
• 9:05 Real-World Example: The $26 “Rinse”
• 10:56 Red Flags Patients Should Watch For
• 12:39 How to Report Suspected Fraud in Texas
• 16:14 Protect Yourself: In-Network & Preapprovals
• 18:23 Role-Play: Handling a Surprise Bill
• 20:00 Key Takeaways & Encouragement to Report
• 21:01 Holiday Promo: The Santa Steven
• 24:20 Book Plug & Musical Outro

Transcript

Steven: 0:00

There once was a ship that put to sea. The name of the ship was a bully of tea. The winds blew up her bird upon below my bully boy's boat. Soon the Willaman comes to bring us sugar and tea and rum. One thing when tongin is done we'll take our leave and go. Health news with Steven and Mady. As far as affairs, the fight's still on, the lines not caught, and the whales not gone. The Willeman makes us regular code to encourage the captain crew and go. The Willeman come to bring us sugar and tea and mum. One day when the tummy is done, we'll take a leave and go. One day when the summons done will take a leave and go.

Mady: 1:04

And I'm Mady. In today's episode, we are diving into a shady corner of dental care, insurance fraud by dentists, especially the practice, sometimes called double dipping or overbilling, and how patients can arm themselves, spot red flags, and report wrongdoing. Stephen and I recently experienced that firsthand. We will not name the dentist, but believe me, they were totally committing fraud.

Steven: 1:35

Yep. Dentist jokes aside, this is serious stuff. It impacts your wallet, your insurance premiums, and trust the system. Before we get started, I need to read a disclaimer. Maddie and I are not doctors or nurses. We do not diagnose or treat patients. Anything we share on this podcast is for educational purposes only and does not substitute for professional medical advice. We advise listeners to consult a medical professional or health care provider if they seek medical advice, diagnosis, or treatment. That's right. So let's dig in. Okay, first, let's define terms. Insurance fraud in dentistry arises when a dentist submits claims to an insurer that misrepresent the service, the cost, or even whether the service was provided. It might involve upcoding, which means billing a more expensive procedure than what was done, unbundling, which means breaking a standard package into multiple codes to increase the total reimbursement, or phantom billing, billing for services never performed. Or waiving co-payments and misrepresenting that to the insurer.

Mady: 2:58

And double dipping is sort of a colloquial way of saying billing twice. For example, billing both the patient and insurer for the same service, or billing one insurer and then after getting paid, billing another insurer or paying again or payer again. Sometimes dentists may claim, well, the insurance didn't pay much, so I have to charge you shifting blame onto the insurer.

Steven: 3:31

Exactly. Dentists may tell their patients, the insurance company forced me to code it this way. It's not my choice, or I'm just following their rules, hoping to deflect suspicion. But behind many of these claims are profit incentives. In other words, folks, they're just outright lying to you to fatten their pocketbook.

Mady: 3:54

And please understand, not every questionable billing is intentional fraud. Some may stem from honest coding mistakes or confusion about coverage rules. But when patterns emerge, repeated overbilling, systematic upcoding, that's when fraud comes into play. Let's talk about ways the industry and investigative bodies have discovered that dentists or dental practices sometimes double charge or overbill. Here are several documented or suspected tactics. One, phantom billing or billing for services not performed, submitting claims for cleanings, x-rays, or procedures that were never done. For example, a dentist in California was convicted of billing for hundreds of root canal never canals never done, or claiming work on teeth that didn't exist. Two, opcoating, billing a more complex and expensive procedure that what was actually done. Three, unbundling, also called code splitting. Taking a procedure that is normally bundled and billing each component separately to increase the total. For example, charging each face of a procedure separately rather than as one uh composite procedure. And I'm quite sure that this is what my dentist was doing uh for my for my implant when I asked for the estimate. Four waiving or hiding co-payments or deductibles. Some dentists may tell the patient, don't worry, we'll waive your copay, but still bill full amount to the insurance, misrepresenting what's due. Then that can be viewed as over billing or misrepresentation. If the dentist doesn't disclose to the insurer that they've uh waived the copay, the insurer is billed for more than what would be appropriate. Five, double billing duplicate claims, submitting the same procedure multiple times across payers or billing a patient and an insurer for the same service. Six phantom upgrades or cross-charging premium materials, claiming more expensive materials than actually used, claiming a premium crown when a standard crown was used, or charging multiple filling surfaces when only one was treated. Seven, misrepresenting diagnosis or necessity, falsifying or exaggerating diagnosis to justify unnecessary treatments. Eight, backdating, adding procedures after the fact or lumping additional services later. Some practices may recode or add procedures after the fact once they see insurance coverage limits. Nine, waiv excess or writing off the patient's portion secretly. The dentist claims a higher amount to insurance than tells the patients, oh, we'll just waive your portion, but the insurer paid more than they should. This is deceptive.

Steven: 7:41

In short, many of these are variations on misrepresentation, coding inflation, or billing tricks. The profit margin in dental care and the complexity of coding create opportunities for abuse.

Mady: 7:56

And the damage isn't just to insurance companies, it can raise premiums for everyone, increase out-of-pocket costs, and erode trust in dentistry.

Steven: 8:06

We mentioned earlier how some dentists, when challenged, deflect by saying, the insurer forced me to code that way, or I had no choice. Let's unpack that a little bit. Dental practices often negotiate contracts with payers, insurance companies, that set allowable codes, reimbursement rates, and limitations. In some cases, dentists may claim that insurers disallowed codes, downcoded their claims, or forced bundling or reductions. However, that doesn't excuse intentionally misrepresenting a service to the insurer, especially when the patient is simultaneously billed or when inflated charges are made. Remember, you got a billing thing on your bill that said uh gingivital rinse or gin ginger something rinse. And it was nothing more than tap water coming out of the dental tool to rinse your mouth out after they cleaned it. It had nothing in it to prevent cavities or otherwise. But you got billed how much for that? $26. $26 for tap water. Wow, man.

Mady: 9:20

Well, and when I called the insurance, they told me that it has to be something that they are uh putting in my mouth with a medication. And when I when I called the the dentist office, they told me that it's the water that they rinse my mouth with. And I asked I asked the the lady I was talking to on the phone, I said, so you are charging me for the water that you risked that you rinse my rinsed my mouth with. I said, it sounds like us, the patients, are paying uh your water bill because if you are charging everybody $26, it's insane. And they lied to me because they said, oh, it was covered by the insurance, but uh until the end of 20 of the beginning of 2025, but now they stop covering it and and we have to charge you. So that is um a lie. So the blame, the insurance defense is uh is a handy cover, and that's exactly what they've done uh to me. And for many patients, dental coding is opaque. Most patients don't know the difference between a comprehensive exam or a profit cleaning. So when they are told we have to code it this way, it can sound plausible. The insurance representative told me that they are processing the claim the way the dentist office is coding it. So it's on them on the dental office, dentist office.

Steven: 10:50

Absolutely. And here's some warning signs. You get a statement showing you owe nothing or a small copay, but your insurer's explanation of benefits shows an unusually high build amount of denial. Your insurer denies or reduces payment for a procedure, but your dentists insist I billed it correctly, you'll have to pay the difference, even though their contract may limit balanced billing. Repeat extras or add-on codes you weren't told about. Multiple billing entries for similar services on the same day. Very complex treatment codes when the work seems straightforward.

Mady: 11:36

Bottom line, if something seems weird, a big surprise bill or premium coding, ask questions. That's exactly what I did. Request a copy of what was submitted to your insurer, compare it to your explanation of benefits, and ask for justification.

Steven: 11:58

So if you suspect your dentist is committing insurance fraud, here's how to take action. For dental licensing and regulatory complaints in Texas, contact the Texas State Board of Dental Examiners, TSBDE. They handle the complaints about licensed dentists' professional conduct, including fraudulent billing practices. Email your complaints to complaints at TSBDE.texas.gov. Or fax them at 512-649-2732. Or you can postal mail them Texas State Board of Dental Examiners Attention Investigations Division 1801 Congress Avenue Suite 8600, Austin, Texas 78701. Also, the TSBDE publishes a fraud hotline. Contact Robert Smith Investigations and Audit Support Manager or the TSBDE's fraud hotline at 512 936 9500. For insurance fraud or consumer protection, the Texas Department of Insurance Fraud Unit. Their phone number or hotline 1800-252-3439. Alternate number 1888-327-8818. Or email fraud report at tdi.texas.gov. If the provider is billing Medicaid or CHIP, you can report to Texas Health and Human Services Office of Inspector General. OIG fraud hotline 1-800-346-6184. The OIG handles suspected fraud, waste, or abuse by Medicaid providers, including dentists. Also, for general health care fraud or deceptive practices, the Texas Office of Attorney General's Consumer Protection Division is a resource. The National Insurance Crime Bureau lets you report overall insurance fraud by calling 1-800-TELNICB, or numerically, that's 1-800-835-6422. What to include in your complaint? When submitting, provide as much detail as you can, the dentist's name, address, practice name, dates of the treatment or billing, copies of bills, explanation of benefits, any statements or communications from the dentist, evidence of duplicate billing codes or inconsistencies, your signature and contact if required by on a form.

Mady: 15:06

A quick note when you report to the TDE fraud unit, the statute 701.052 of the Texas Insurance Code protects you, the reporter, from civil liability when reporting in good faith. Also, be aware that the TSBDE does not accept anonymous complaints. You'll need to provide your name and contact information.

Steven: 15:34

One of the best defenses is to use your insurance plan's tools to pick a dentist in your network. This helps in a few ways. In-network dentists have contractual obligations to follow insurer billing rules and usually cannot arbitrarily balance bill beyond certain limits. The insurance company is more likely to audit claims from in-network providers. You give yourself more recourse by staying with the safe zone of your plan.

Mady: 16:08

Here's how to proceed. Check your insurer provider directory. On your insurer's website, use their finda dentist slash provider search tool and filter by network, location, zip code, and specialty. If possible, call the insurer and ask for a list of high-quality dentists in your area. That's what I had to do. Verify provider credentials and history once you have a name, check for disciplinary actions or consumer complaints, for example, via state dental board or consumer protection agencies. Ask the dentist's office whether they accept your plan in network and whether they ever balance bill. Ask upfront about billing practices. Before treatment, request an estimate of benefits slash predetermination from your insurer, which is a preliminary review by the insurer of what they will cover for a proposed treatment. Ask the dentist to provide the exact code or codes they intend to bill and clarify what you will owe. Then compare that to the insurer's response. Compare multiple options. Get cost estimates from a couple of dentists in network for non-emergency work. This can help spot out liars. Use insurers complaint or review mechanisms. Many dental plants, insurance plants allow members to dispute claims or request audits if you suspect missbilling, follow up if there are discrepancies. Maintain documentation. Keep your EOBs, invoices, notes, and any correspondence. If something odd arises, you'll have the records to back your claim.

Steven: 18:13

The combination of selecting in-network providers and proactively asking questions reduces your exposure to bad actors.

Mady: 18:23

Time for a little role play. You, Steven, are our listener, and you just got a bill that surprises you. Let's walk through it. Okay.

Steven: 18:37

Hey, I got this statement. I was told my cleaning will cost $70, but the insurer's explanation of benefits showed they billed $250. And the dentist said, I owe $180.

Mady: 18:51

What's going on? Okay. First, ask for a copy of what was submitted to the insurer. Compare that to the EOB explanation of benefits. Second, ask the dentist which codes did you bill and why? Third, request a predetermination or estimate from your insurer to see what they will approve before work is done.

Steven: 19:22

Oh, we always bill high so that insurers have room to adjust.

Mady: 19:28

Yeah. Bear with me. That's exactly the kind of explanation that raises a red flag. Ask for written documentation. If this uh keeps happening, file a complaint. So if your dentist tells you it's the insurance fault, I just followed their rules, you can respond. Then please show me your rule book. I want to read along.

Steven: 19:53

Exactly. Humor helps, but it also keeps you alert.

Mady: 19:59

That wraps up today's discussion on dental insurance fraud and double dipping. If any listener suspects a dentist may have treated them unfairly, don't stay silent. Document, ask questions, and report. Definitely.

Steven: 20:16

Absolutely. Knowledge is power. We'll post in the show notes those numbers and email addresses for Texas. And if you're in another state, we recommend checking your state's insurance department and dental board.

Mady: 20:32

If you like today's show, please subscribe, leave a review, and share with friends or family who might benefit. We are here to help you navigate health. Minus the tooth fairy tax.

Steven: 20:46

The only tax you want from your dentist is for floss you forgot. Well, thanks for listening. See you next time on Health News with Stephen and Maddie. Now for a few announcements from Santa. There are only 72 days left until Christmas. Call the Santa Stephen to come and visit. And now for a commercial announcement from our man from the North Pole, the Santa Stephen. He's coming soon! You better watch out. You better not cry. You better not. I'm telling you why. Why? Stand up is coming to time. Gather up. He's making a list. He's checking it twice. He's gonna find out who's naughty and nice. Santa Claus is coming to time. This holiday season, bring the magic of Christmas right to your doorstep with the Santa Stephen. Imagine the joy on your child's face when Santa and Mrs. Claus step into your home for a personal visit, stories, laughters, photos, and memories to last a lifetime. Ho ho ho! Merry Christmas!

Mady: 22:17

And don't forget, we even bring sweet holidays cheer for parents too.

Steven: 22:23

Hosting a party? Big or small, the Santa Stephen brings the holiday sparkle. From the family gatherings to corporate events, we spread joy in every setting. One on one with your little one or a crowd of excited children, the Santa Stephen makes every moment magical. Bring holiday spirit to your community. Parades, festivals, and tree lighting ceremonies grow brighter with the Santa Stephen. And for the sweetened surprise, your child can receive a personalized letter straight from Santa's desk, signed, sealed, and delivered with a touch of Christmas magic.

Mady: 23:18

Every letter is filled with love, joy, and just the sprinkle of North Paul sparkle.

Steven: 23:26

Whether it's your home, your office, your school, or your town, let the Santa Stephen make this holiday unforgettable. Ho ho ho! We'll see you this Christmas.

Mady: 23:42

Because every family and every business deserves a little extra holiday magic.

Steven: 23:50

The Santa Stephen, where Christmas comes to life. You better watch out. You better not cry. You better not cut. I'm telling you why. Santa Claus is coming to time. The big fat man with a long white beard. He's coming to time. To book an event, party, or some one on one time with The Santa Steven, call 469-230-5956 or email steven@ thesantasteven.com. That's S T E V E N@ thesantasteven. com. And we hope you have a very wonderful holiday season. And don't forget, folks, go on Amazon and get your copy of Achieve Optimal Brain Health with Nutrition by Stefan McDermott, an easy to follow holistic guide to help boost your memory, mental clarity, and cognitive function with recipes and examples anyone can use daily. Until next week, we'll see you at the top. Goodbye. Goodbye. There once was a ship that put to sea. The name of the ship was a bully of tea. The winds blew up her bird upon below my bully boys blow. Soon may the willow man come to bring us sugar and tea and rum. One day when the tournament is done, we'll take a leave and go. Health news with Steven and Mady. As far as affairs, the fight's still on, the lane's not cut, and the wheels not gone. The willow man makes his regular call to encourage the captain crew and go. Soon be the willowman come, bring us sugar and tea and rum. One day when the tummy is done, we'll take a leave and go. Soon may the willow man come, bring us sugar and tea and rum. One day when the tummy is done, we'll take a leave and go.