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

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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: [phone]Texas 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: [e-mail] Department of Insurance 
• Texas State Board of Dental Examiners (TSBDE) — for complaints about dentists
   
  • Complaints email: [e-mail] State Board of Dental Examiners 
• Fax: [phone] Texas State Board of Dental Examiners 
• Phone (fraud / investigations): [phone] Texas State Board of Dental Examiners 
• Texas HHSC / OIG (Medicaid / provider fraud)
   

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Episode Transcript

Steven (00:00):
There once was a ship that put to sea.
The name of the ship was abully of tea.
The winds blew up her bird uponbelow my bully boy's boat.
Soon the Willaman comes tobring us sugar and tea and rum.
One thing when tongin is donewe'll take our leave and go.
Health news with Steven andMady.

(00:24):
As far as affairs, the fight'sstill on, the lines not caught,
and the whales not gone.
The Willeman makes us regularcode to encourage the captain
crew and go.
The Willeman come to bring ussugar and tea and mum.
One day when the tummy is done,we'll take a leave and go.
One day when the summons donewill take a leave and go.

Mady (01:04):
And I'm Mady.
In today's episode, we arediving into a shady corner of
dental care, insurance fraud bydentists, especially the
practice, sometimes calleddouble dipping or overbilling,
and how patients can armthemselves, spot red flags, and
report wrongdoing.

(01:24):
Stephen and I recentlyexperienced that firsthand.
We will not name the dentist,but believe me, they were
totally committing fraud.

Steven (01:35):
Yep.
Dentist jokes aside, this isserious stuff.
It impacts your wallet, yourinsurance premiums, and trust
the system.
Before we get started, I needto read a disclaimer.
Maddie and I are not doctors ornurses.
We do not diagnose or treatpatients.
Anything we share on thispodcast is for educational

(01:58):
purposes only and does notsubstitute for professional
medical advice.
We advise listeners to consulta medical professional or health
care provider if they seekmedical advice, diagnosis, or
treatment.
That's right.
So let's dig in.
Okay, first, let's defineterms.

(02:21):
Insurance fraud in dentistryarises when a dentist submits
claims to an insurer thatmisrepresent the service, the
cost, or even whether theservice was provided.
It might involve upcoding,which means billing a more
expensive procedure than whatwas done, unbundling, which
means breaking a standardpackage into multiple codes to

(02:44):
increase the totalreimbursement, or phantom
billing, billing for servicesnever performed.
Or waiving co-payments andmisrepresenting that to the
insurer.

Mady (02:58):
And double dipping is sort of a colloquial way of saying
billing twice.
For example, billing both thepatient and insurer for the same
service, or billing one insurerand then after getting paid,
billing another insurer orpaying again or payer again.

(03:21):
Sometimes dentists may claim,well, the insurance didn't pay
much, so I have to charge youshifting blame onto the insurer.

Steven (03:31):
Exactly.
Dentists may tell theirpatients, the insurance company
forced me to code it this way.
It's not my choice, or I'm justfollowing their rules, hoping
to deflect suspicion.
But behind many of these claimsare profit incentives.
In other words, folks, they'rejust outright lying to you to

(03:52):
fatten their pocketbook.

Mady (03:54):
And please understand, not every questionable billing is
intentional fraud.
Some may stem from honestcoding mistakes or confusion
about coverage rules.
But when patterns emerge,repeated overbilling, systematic
upcoding, that's when fraudcomes into play.

(04:17):
Let's talk about ways theindustry and investigative
bodies have discovered thatdentists or dental practices
sometimes double charge oroverbill.
Here are several documented orsuspected tactics.
One, phantom billing or billingfor services not performed,

(04:41):
submitting claims for cleanings,x-rays, or procedures that were
never done.
For example, a dentist inCalifornia was convicted of
billing for hundreds of rootcanal never canals never done,
or claiming work on teeth thatdidn't exist.

(05:04):
Two, opcoating, billing a morecomplex and expensive procedure
that what was actually done.
Three, unbundling, also calledcode splitting.
Taking a procedure that isnormally bundled and billing

(05:26):
each component separately toincrease the total.
For example, charging each faceof a procedure separately
rather than as one uh compositeprocedure.
And I'm quite sure that this iswhat my dentist was doing uh
for my for my implant when Iasked for the estimate.

(05:49):
Four waiving or hidingco-payments or deductibles.
Some dentists may tell thepatient, don't worry, we'll
waive your copay, but still billfull amount to the insurance,
misrepresenting what's due.
Then that can be viewed as overbilling or misrepresentation.

(06:11):
If the dentist doesn't discloseto the insurer that they've uh
waived the copay, the insurer isbilled for more than what would
be appropriate.
Five, double billing duplicateclaims, submitting the same
procedure multiple times acrosspayers or billing a patient and

(06:35):
an insurer for the same service.
Six phantom upgrades orcross-charging premium
materials, claiming moreexpensive materials than
actually used, claiming apremium crown when a standard
crown was used, or chargingmultiple filling surfaces when

(06:56):
only one was treated.
Seven, misrepresentingdiagnosis or necessity,
falsifying or exaggeratingdiagnosis to justify unnecessary
treatments.
Eight, backdating, addingprocedures after the fact or
lumping additional serviceslater.
Some practices may recode oradd procedures after the fact

(07:19):
once they see insurance coveragelimits.
Nine, waiv excess or writingoff the patient's portion
secretly.
The dentist claims a higheramount to insurance than tells
the patients, oh, we'll justwaive your portion, but the
insurer paid more than theyshould.

(07:39):
This is deceptive.

Steven (07:41):
In short, many of these are variations on
misrepresentation, codinginflation, or billing tricks.
The profit margin in dentalcare and the complexity of
coding create opportunities forabuse.

Mady (07:56):
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 (08:06):
We mentioned earlier how some dentists, when challenged,
deflect by saying, the insurerforced me to code that way, or I
had no choice.
Let's unpack that a little bit.
Dental practices oftennegotiate contracts with payers,
insurance companies, that setallowable codes, reimbursement

(08:28):
rates, and limitations.
In some cases, dentists mayclaim that insurers disallowed
codes, downcoded their claims,or forced bundling or
reductions.
However, that doesn't excuseintentionally misrepresenting a
service to the insurer,especially when the patient is

(08:50):
simultaneously billed or wheninflated charges are made.
Remember, you got a billingthing on your bill that said uh
gingivital rinse or gin gingersomething rinse.
And it was nothing more thantap water coming out of the
dental tool to rinse your mouthout after they cleaned it.
It had nothing in it to preventcavities or otherwise.

(09:13):
But you got billed how much forthat?
$26.
$26 for tap water.
Wow, man.

Mady (09:20):
Well, and when I called the insurance, they told me that
it has to be something thatthey are uh putting in my mouth
with a medication.
And when I when I called thethe dentist office, they told me
that it's the water that theyrinse my mouth with.
And I asked I asked the thelady I was talking to on the

(09:40):
phone, I said, so you arecharging me for the water that
you risked that you rinse myrinsed my mouth with.
I said, it sounds like us, thepatients, are paying uh your
water bill because if you arecharging everybody $26, it's
insane.
And they lied to me becausethey said, oh, it was covered by

(10:01):
the insurance, but uh until theend of 20 of the beginning of
2025, but now they stop coveringit and and we have to charge
you.
So that is um a lie.
So the blame, the insurancedefense is uh is a handy cover,
and that's exactly what they'vedone uh to me.

(10:22):
And for many patients, dentalcoding is opaque.
Most patients don't know thedifference between a
comprehensive exam or a profitcleaning.
So when they are told we haveto code it this way, it can
sound plausible.
The insurance representativetold me that they are processing
the claim the way the dentistoffice is coding it.

(10:45):
So it's on them on the dentaloffice, dentist office.

Steven (10:50):
Absolutely.
And here's some warning signs.
You get a statement showing youowe nothing or a small copay,
but your insurer's explanationof benefits shows an unusually
high build amount of denial.
Your insurer denies or reducespayment for a procedure, but
your dentists insist I billed itcorrectly, you'll have to pay

(11:14):
the difference, even thoughtheir contract may limit
balanced billing.
Repeat extras or add-on codesyou weren't told about.
Multiple billing entries forsimilar services on the same
day.
Very complex treatment codeswhen the work seems

(11:34):
straightforward.

Mady (11:36):
Bottom line, if something seems weird, a big surprise bill
or premium coding, askquestions.
That's exactly what I did.
Request a copy of what wassubmitted to your insurer,
compare it to your explanationof benefits, and ask for
justification.

Steven (11:58):
So if you suspect your dentist is committing insurance
fraud, here's how to takeaction.
For dental licensing andregulatory complaints in Texas,
contact the Texas State Board ofDental Examiners, TSBDE.
They handle the complaintsabout licensed dentists'
professional conduct, includingfraudulent billing practices.

(12:21):
Email your complaints tocomplaints at TSBDE.texas.gov.
Or fax them at 512-649-2732.
Or you can postal mail themTexas State Board of Dental

(12:42):
Examiners AttentionInvestigations Division 1801
Congress Avenue Suite 8600,Austin, Texas 78701.
Also, the TSBDE publishes afraud hotline.
Contact Robert SmithInvestigations and Audit Support

(13:04):
Manager or the TSBDE's fraudhotline at 512 936 9500.
For insurance fraud or consumerprotection, the Texas
Department of Insurance FraudUnit.
Their phone number or hotline[phone].

(13:29):
Alternate number 1888-327-8818.
Or email fraud report attdi.texas.gov.
If the provider is billingMedicaid or CHIP, you can report

(13:50):
to Texas Health and HumanServices Office of Inspector
General.
OIG fraud hotline[phone].
The OIG handles suspectedfraud, waste, or abuse by
Medicaid providers, includingdentists.
Also, for general health carefraud or deceptive practices,

(14:14):
the Texas Office of AttorneyGeneral's Consumer Protection
Division is a resource.
The National Insurance CrimeBureau lets you report overall
insurance fraud by calling1-800-TELNICB, or numerically,
that's 1-800-835-6422.

(14:39):
What to include in yourcomplaint?
When submitting, provide asmuch detail as you can, the
dentist's name, address,practice name, dates of the
treatment or billing, copies ofbills, explanation of benefits,
any statements or communicationsfrom the dentist, evidence of
duplicate billing codes orinconsistencies, your signature

(15:02):
and contact if required by on aform.

Mady (15:06):
A quick note when you report to the TDE fraud unit,
the statute 701.052 of the TexasInsurance Code protects you,
the reporter, from civilliability when reporting in good
faith.
Also, be aware that the TSBDEdoes not accept anonymous

(15:29):
complaints.
You'll need to provide yourname and contact information.

Steven (15:34):
One of the best defenses is to use your insurance plan's
tools to pick a dentist in yournetwork.
This helps in a few ways.
In-network dentists havecontractual obligations to
follow insurer billing rules andusually cannot arbitrarily
balance bill beyond certainlimits.

(15:56):
The insurance company is morelikely to audit claims from
in-network providers.
You give yourself more recourseby staying with the safe zone
of your plan.

Mady (16:08):
Here's how to proceed.
Check your insurer providerdirectory.
On your insurer's website, usetheir finda dentist slash
provider search tool and filterby network, location, zip code,
and specialty.
If possible, call the insurerand ask for a list of

(16:29):
high-quality dentists in yourarea.
That's what I had to do.
Verify provider credentials andhistory once you have a name,
check for disciplinary actionsor consumer complaints, for
example, via state dental boardor consumer protection agencies.
Ask the dentist's officewhether they accept your plan in

(16:53):
network and whether they everbalance bill.
Ask upfront about billingpractices.
Before treatment, request anestimate of benefits slash
predetermination from yourinsurer, which is a preliminary
review by the insurer of whatthey will cover for a proposed

(17:13):
treatment.
Ask the dentist to provide theexact code or codes they intend
to bill and clarify what youwill owe.
Then compare that to theinsurer's response.
Compare multiple options.
Get cost estimates from acouple of dentists in network
for non-emergency work.

(17:34):
This can help spot out liars.
Use insurers complaint orreview mechanisms.
Many dental plants, insuranceplants allow members to dispute
claims or request audits if yoususpect missbilling, follow up

(17:55):
if there are discrepancies.
Maintain documentation.
Keep your EOBs, invoices,notes, and any correspondence.
If something odd arises, you'llhave the records to back your
claim.

Steven (18:13):
The combination of selecting in-network providers
and proactively asking questionsreduces 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 willcost $70, but the insurer's
explanation of benefits showedthey billed $250.
And the dentist said, I owe$180.

Mady (18:51):
What's going on?
Okay.
First, ask for a copy of whatwas submitted to the insurer.
Compare that to the EOBexplanation of benefits.
Second, ask the dentist whichcodes did you bill and why?
Third, request apredetermination or estimate

(19:12):
from your insurer to see whatthey 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 ofexplanation that raises a red
flag.
Ask for written documentation.
If this uh keeps happening,file a complaint.
So if your dentist tells youit's the insurance fault, I just
followed their rules, you canrespond.

(19:49):
Then please show me your rulebook.
I want to read along.

Steven (19:53):
Exactly.
Humor helps, but it also keepsyou alert.

Mady (19:59):
That wraps up today's discussion on dental insurance
fraud and double dipping.
If any listener suspects adentist may have treated them
unfairly, don't stay silent.
Document, ask questions, andreport.
Definitely.

Steven (20:16):
Absolutely.
Knowledge is power.
We'll post in the show notesthose numbers and email
addresses for Texas.
And if you're in another state,we recommend checking your
state's insurance department anddental board.

Mady (20:32):
If you like today's show, please subscribe, leave a
review, and share with friendsor family who might benefit.
We are here to help younavigate 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 HealthNews with Stephen and Maddie.
Now for a few announcementsfrom Santa.
There are only 72 days leftuntil Christmas.
Call the Santa Stephen to comeand visit.

(21:07):
And now for a commercialannouncement from our man from
the North Pole, the SantaStephen.
He's coming soon! You betterwatch out.

(21:27):
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'snaughty and nice.
Santa Claus is coming to time.

(21:48):
This holiday season, bring themagic of Christmas right to your
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Imagine the joy on your child'sface when Santa and Mrs.
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(22:12):
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 Stephenbrings the holiday sparkle.
From the family gatherings tocorporate events, we spread joy
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(22:45):
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(23:10):
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Mady (23:18):
Every letter is filled with love, joy, and just the
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Steven (23:26):
Whether it's your home, your office, your school, or
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Mady (23:42):
Because every family and every business deserves a little
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Steven (23:50):
The Santa Stephen, where Christmas comes to life.
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(24:11):
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To book an event, party, or someone on one time with The Santa
Steven, call 469-230-5956 oremail steven@

(24:36):
thesantasteven.com.
That's S T E V E N@thesantasteven.
com.
And we hope you have a verywonderful holiday season.
And don't forget, folks, go onAmazon and get your copy of

(24:58):
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McDermott, an easy to followholistic guide to help boost
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Until next week, we'll see youat the top.

(25:19):
Goodbye.
Goodbye.
There once was a ship that putto sea.
The name of the ship was abully of tea.
The winds blew up her bird uponbelow my bully boys blow.
Soon may the willow man come tobring us sugar and tea and rum.
One day when the tournament isdone, we'll take a leave and go.

(25:42):
Health news with Steven andMady.
As far as affairs, the fight'sstill on, the lane's not cut,
and the wheels not gone.
The willow man makes his regularcall 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.

(26:05):
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.