An insurer sends a records request for six crowns billed in one month on one provider. The clinical notes support four of them. The other two were planned, not completed, and the claims went out anyway.
That is one kind of dental fraud. There are several, and they leave different traces. This page sorts them by who is on the receiving end and says what an owner can check in the practice software. Nothing here is legal advice; if you think you have found something, call your attorney and your malpractice carrier before you do anything else.
What makes something fraud rather than an error?
Intent. A claim with the wrong code is an error. The same wrong code used repeatedly because it pays more is fraud. The False Claims Act and state insurance fraud laws cover insurer-facing cases; employment and criminal law cover internal theft. The practice software cannot see intent. It can show you repetition, timing and who was logged in.
What does insurer-facing fraud look like?
These are claims the office sends out.
| Pattern | What the record shows |
|---|---|
| Billing for work not done | A claim with a procedure date and no matching completed procedure, or a procedure completed on paper with no chart note or image |
| Upcoding | A surgical extraction code on a tooth that the note describes as a simple extraction |
| Unbundling | A buildup and a crown billed separately when the plan treats them as one |
| Date shifting | A procedure date moved to fall after a waiting period or inside a benefit year |
| Waiving the patient share routinely | Co-pays written off as courtesy on every in-network claim |
| Billing under another provider | Procedures completed by a hygienist or associate submitted under the owner’s NPI when the plan does not allow it |
What an owner can check: completed procedures with no chart note on the same date, claims where the procedure date differs from the appointment date, and the non-contractual adjustment share by user from the write-off report. In Open Dental the procedure dates sit in procedurelog; in Eaglesoft the service rows are type S in transactions_header.
What does patient-facing fraud look like?
- Charging for a higher-fee material than was used.
- Collecting a patient share that insurance later covers, and not refunding the credit.
- Selling treatment that imaging does not support.
The record for the second one is simple: accounts with a credit balance older than 60 days. Run it monthly. In most offices the list exists and is innocent, but it should be shrinking, not growing.
What does internal fraud look like?
This is the embezzlement case: money the practice earned that never reached the practice.
- Cash payments taken and the balance cleared with an adjustment.
- A payment deleted after the deposit was prepared.
- Refunds issued to a card that is not the patient’s.
- Insurance checks diverted to an account the office does not own.
- A ghost vendor paid from the practice’s bank account.
The first three live in the practice software and are covered on the deleted payments and warning signs pages. The last two live in the bank statements, which is why the owner, not the bookkeeper, should open them.
The ACFE Report to the Nations (2024) put the median occupational fraud loss at $145,000 and the median duration before detection at 12 months, across all industries. The duration figure is the useful one: a monthly review shortens it.
How do you check without accusing anyone?
- Pick one pattern from the tables above.
- Run the report for the last 90 days. Write down what a normal month looks like.
- Pull the five rows that look least normal and read the full account ledger and chart for each.
- If a row still looks wrong after that, preserve the audit log, then talk to your attorney. Do not change permissions or confront anyone first; both can destroy the record you need.
Most rows turn out to be training problems. Training problems are also worth fixing, because insurers audit on patterns and do not ask about intent until later.
What Calibic adds
Protect is LIVE. Calibic keeps a read-only, time-stamped record of payment and adjustment changes from Open Dental, Dentrix and Eaglesoft, raises alerts on a small set of patterns (a completed payment deleted, a courtesy adjustment on a paid account, an adjustment type that does not fit the patient’s insurance), and keeps the before and after values as evidence. It does not review clinical notes or images, so it cannot tell you whether a crown was clinically justified. It never writes to the practice software and it does not decide who is at fault.
Next step: the Protect product page.