5 Dental Fraud Acts That Can Send You Straight to Jail

Many dental teams do not intend to commit fraud. Most cases come from poor documentation, inconsistent systems, or a lack of awareness about compliance rules. This is why strong dental revenue cycle management is not just about getting paid faster. It is also about protecting your practice from actions that could put you at legal risk.

This awareness-driven guide breaks down five dental fraud acts that can result in criminal charges and explains how structured dental RCM services and experienced dental RCM service provider support help practices avoid them.

Why Knowing Fraud Risks Helps Your Practice Stay Safe

Insurance companies monitor claim patterns closely. State boards investigate complaints. Federal programs take action when billing looks suspicious. Even honest mistakes can look like intentional fraud when they repeat or create unusual billing patterns.

Understanding what qualifies as fraud helps your practice:

• avoid legal risk
• prevent accidental red flags
• maintain clean documentation
• support ethical billing
• protect your license and reputation
• keep your revenue cycle compliant

Awareness is protection. The more your team understands these risks, the safer your practice becomes.

1. Billing for Services Not Performed

This is the most serious and most common type of dental fraud. It includes any situation where a claim is submitted for a procedure that did not actually happen.

Examples include:

• Charging for a crown when only a filling was placed
• Billing SRP when the patient only received a prophy
• Submitting a claim for X-rays not taken
• Charging for a visit the patient never attended

Even if it happens once, payers treat this as criminal fraud.

Why it leads to jail:

It counts as intentional theft from insurance programs. State and federal laws consider this a felony.

How to avoid it:

• Cross-check notes with codes
• Require daily documentation sign-off
• Use an internal audit routine
• Never submit until the provider confirms the service

Clean documentation is the strongest defense.

2. Upcoding and Inflating Procedures

Upcoding means charging for a more expensive procedure than what was actually done. Sometimes this happens because a provider uses a similar code or picks from memory, but payers see it as intentional misrepresentation.

Examples:

• Billing a crown instead of a large filling
• Charging for a comprehensive exam instead of a periodic exam
• Listing SRP when the patient did not qualify for it
• Claiming a multi-surface filling for a one-surface restoration

Why it leads to jail:

Upcoding is viewed as knowingly increasing reimbursement. It becomes fraud when repeated or documented poorly.

How to avoid it:

• Follow CDT rules strictly
• Use coding checklists
• Train teams yearly
• Use claim scrubbers to detect mismatches
• Let dental RCM services verify accuracy

Correct coding = safe billing.

3. Unbundling Procedures That Must Be Billed Together

Unbundling is breaking one covered procedure into multiple separate codes to increase payment. Payers track this behavior and investigate quickly when they see unusual patterns.

Examples:

• Billing polishing separately from a prophy
• Charging per tooth for SRP instead of per quadrant
• Separating components of a crown instead of using the crown code
• Billing multiple X-rays when a bundle should be used

Why it leads to jail:

Unbundling is considered intentional manipulation of billing rules for higher reimbursement.

How to avoid it:

• Use PMS bundling alerts
• Train providers on what must be billed together
• Follow payer-specific bundling rules
• Let an experienced dental RCM service provider review high-risk claims

Consistent workflows protect your practice.

4. Altering Dates of Service or Documentation

Changing dates or altering documentation to fit payer rules is considered falsification. Even small changes can trigger a fraud investigation.

Examples:

• Backdating a claim to meet timely filing
• Moving a procedure date to match coverage requirements
• Editing notes after denial without timestamp
• Adjusting documentation to fit a higher-paying code

Why it leads to jail:

Altering records violates state law, insurance rules, and federal healthcare fraud statutes.

How to avoid it:

• Lock notes after provider sign-off
• Disable backdating in your PMS
• Document amendments clearly with timestamps
• Train all staff on compliance rules
• Use role-based access controls

Documentation must match reality, always.

5. Waiving Copays Without Proper Documentation

Many practices waive patient copays to “help the patient,” but to insurance companies, this can look like you are inflating claims and hiding the patient’s obligation.

Fraud occurs when:

• Copays are waived without proving financial hardship
• Discounts are applied secretly
• The practice tells patients they “won’t owe anything”
• Bills are altered to cover up waived fees

Why it leads to jail:

It creates the impression of insurance manipulation and false reporting of fees.

How to avoid it:

• Have a documented hardship policy
• Record every waiver with explanation
• Never promise patients that insurance will pay 100%
• Ensure your team uses consistent language

Transparency keeps your practice safe.

Why Compliance Is a Revenue Protection Strategy

Dental fraud is rarely intentional, but intent does not matter to payers or regulators. Patterns matter. Documentation matters. Consistency matters. Small shortcuts repeated over time can trigger audits, penalties, loss of licensure, and in the worst cases, criminal charges.

The safest practices are not the ones that rush billing. They are the ones that operate with structure. Clean documentation, accurate coding, clear financial policies, and disciplined claim review protect both revenue and reputation. This is where strong dental revenue cycle management becomes more than an operational function, it becomes a safeguard.

CareRevenue helps dental organizations reduce compliance risk by enforcing structured RCM workflows, documentation accuracy, and denial prevention standards that align with payer and regulatory expectations. When revenue systems are built on clarity and accountability, practices stay compliant, protected, and focused on patient care, not legal exposure.

In today’s environment, ethical billing is not just good practice. It is essential protection.