Billing errors related to incorrect fee schedules and overbilling are among the top reasons for dental claim denials. These mistakes can lead to payment delays, revenue loss, and even compliance issues. Here’s how they happen and how to prevent them.
Common Causes of Fee Schedule Errors & Overbilling:
- Outdated Fee Schedules – Insurance companies periodically update their allowed amounts, and if your practice is billing based on old rates, claims may be denied or underpaid.
- Charging Above the Allowed Amount – When the billed amount exceeds the insurance company’s contracted rate for in-network providers, the excess may be written off or result in a claim denial.
- Incorrect UCR (Usual, Customary, and Reasonable) Charges – For out-of-network providers, insurance companies set UCR rates, and billing outside this range can lead to claim denials or reduced reimbursements.
- Misuse of Procedure Codes for Higher Reimbursement – Upcoding (using a higher-paying procedure code than necessary) can result in audits, claim denials, and legal consequences.
- Bundling & Unbundling Errors – Some procedures are meant to be billed as a single code rather than separate ones. Incorrectly unbundling them can be flagged as overbilling.
- Duplicate Billing – Submitting the same procedure multiple times without justification can lead to immediate denials and may raise fraud concerns.
How to Prevent Fee Schedule Errors & Overbilling:
- Regularly Update Your Fee Schedules – Stay informed about insurance fee schedule updates to ensure accurate billing.
- Verify Contracted Fees for In-Network Plans – Make sure your practice is charging according to the negotiated rates for each insurance provider.
- Use Accurate CDT Codes – Ensure proper coding to avoid upcoding or unbundling issues that may trigger denials.
- Review EOBs for Reimbursement Trends – Explanation of Benefits (EOBs) can help identify discrepancies in reimbursements and highlight underpayments.
- Conduct Periodic Audits – Internal billing audits can help catch errors before claims are submitted.
Bottom Line: Incorrect fee schedules and overbilling not only impact reimbursements but can also lead to compliance risks. Avoid these pitfalls by staying proactive and ensuring your billing practices align with insurance guidelines.