False Claims Act (FCA) and Dental Billing: A Complete Guide

Published by the American Dental Coders Association

Table of Contents

• 1. Introduction to the False Claims Act (FCA)
• 2. Why the FCA Applies to Dental Billing
• 3. Common FCA Violations in Dentistry
• 4. Real-World FCA Case Examples
• 5. Legal Consequences of FCA Violations
• 6. How Dental Practices Can Stay Compliant
• 7. Sample Audit Checklist
• 8. Staff Training and Compliance Culture
• 9. Final Thoughts
• 10. Resources and Help

1. Introduction to the False Claims Act (FCA)

The False Claims Act (FCA) is a federal law that imposes liability on individuals and companies who defraud governmental programs. Originally enacted during the Civil War, the FCA now serves as a powerful tool to combat healthcare fraud — including in dental billing.

• Enacted in 1863; modernized in 1986
• Contains a qui tam provision allowing whistleblowers to sue on the government’s behalf
• Violators may owe triple damages plus civil penalties per false claim

2. Why the FCA Applies to Dental Billing

Dental practices that bill federally funded programs like Medicaid or CHIP fall under FCA scrutiny. Even billing mistakes can become FCA issues if considered “knowingly” false.

Examples include:

• Medicaid-covered dental services
• Federally subsidized dental managed care plans

3. Common FCA Violations in Dentistry

• Upcoding: Billing for more complex or costly services than were performed.
• Unbundling: Separately billing for services that should be combined under one code.
• Billing for services not rendered: Submitting claims for treatments never provided.
• Medical necessity issues: Charging for services not clinically justified.
• Misrepresenting provider credentials: Using another provider’s NPI on a claim.

4. Real-World FCA Case Examples

⚖️ U.S. ex rel. Doe v. XYZ Dental Group (2022)
A dental chain billed Medicaid for fluoride treatments never provided. Settled for $5.2 million.

⚖️ Pediatric Dental Practice in Texas (2020)
Upcoded and billed unnecessary baby root canals. Paid $1.8 million to resolve claims.

⚖️ Whistleblower in Ohio (2018)
Former employee exposed excessive billing. The practice lost its state contract and paid fines.

5. Legal Consequences of FCA Violations

6. How Dental Practices Can Stay Compliant

• Conduct regular internal billing audits
• Ensure documentation supports all billed CDT codes
• Maintain a written compliance plan
• Train staff routinely on compliance updates
• Designate a compliance officer or use third-party compliance support
• Develop and follow a Corrective Action Plan (CAP) for errors

7. Sample FCA Compliance Audit Checklist

• [ ] Are all claims backed by chart notes?
• [ ] Is the billing provider’s NPI accurate?
• [ ] Are CDT codes correctly selected and used?
• [ ] Are refunds for overpayments processed within 60 days?
• [ ] Does the office have a posted whistleblower policy?
• [ ] Are clinical and billing records retained per regulation?

Tip: Perform this checklist at least quarterly.

8. Staff Training and Compliance Culture

Prevention starts with education. Staff must be trained to:

• Recognize coding issues and understand compliance policies
• Report concerns confidentially or anonymously
• Understand what constitutes “knowing” misconduct

9. Final Thoughts

FCA enforcement in dental billing is increasing. With high penalties and public scrutiny, every dental practice must treat billing compliance seriously. By implementing checks and fostering transparency, you protect your business, license, and patients.

10. Resources and Help

• ADCA Membership – Stay informed and access exclusive compliance tools
• Ask-The-Coder – Get free help with coding or billing questions
• Justice.gov – FCA Overview
• OIG Compliance Resources