Strengthening dental payment integrity through smarter claim editing

Fraud, waste, and abuse (FWA) continue to challenge dental plans as overtreatment, miscoding and inappropriate billing practices drive unnecessary costs and weaken payment integrity. For dental payers, the stakes extend beyond financial losses: these issues can also expose members to unnecessary procedures and consume benefits that should be preserved for appropriate care.

With an estimated $198 billion spent on dental care in 2025, and approximately 3–10% of these payments lost annually to FWA, dental payers need more effective ways to identify suspect claims before payment. Growing coding complexity and evolving billing practices make improper claims harder to detect through traditional editing alone. A more advanced approach to dental claim editing can help plans improve payment accuracy, surface emerging risk patterns, and better protect plan resources and member benefits.

By pairing automated dental claim editing with expert clinical, documentation, and coding review, plans can address FWA more proactively—preventing waste, abuse and errors before payment while reducing administrative burden, supporting provider education and avoiding disruption that often accompanies postpay recovery efforts.

What’s driving FWA in dental billing

Dental billing gives providers more discretion and fewer guardrails than medical billing. A few key factors drive FWA risk, including:

• Limited pre-authorization requirements. Medical procedures billed to health plans often require pre-authorization tied to a documented diagnosis. In dental practices, non-surgical procedures like crowns get billed and coded at the discretion of the dentist with no comparable check before the claim is submitted.

• Consolidation and profit-driven performance goals. As more dental practices are acquired by larger organizations, providers are increasingly pressured to align with stakeholder performance targets. This can push practices towards more standardized treatment approaches rather than individualized care plans that are tailored to the needs of the patient.

• Heightened exposure in Medicare Advantage. MA plans can be especially vulnerable to overpayments. Some plans may cap dental benefits, but others place no limit on procedures a provider deems essential—creating an opening for bad actors to overtreat. A patient with a $2,000 dental allowance, for example, may be steered toward unnecessary procedures simply to exhaust the benefit.

• Outside consultants may advise on revenue, not clinical best practices. Many dental offices engage consultants focused on hitting revenue goals, often without grounding in clinical or billing standards. The result is predictable: staff are coached to bundle procedures—billing for a build-up alongside every crown, for instance—even when the build-up is unnecessary, or in some cases, never performed.

Operational impacts of dental FWA

FWA is estimated to cost the U.S. healthcare system hundreds of billions of dollars annually, and dental billing contributes to that burden through overtreatment, miscoding, and other inappropriate reimbursement practices. For dental plans, even a small percentage of improper payments can translate into meaningful losses, especially as claim volume and coding complexity continue to rise.

The downstream effect is broader than overpayment alone: FWA contributes to higher administrative cost, unnecessary utilization, and pressure on premiums and plan resources.

Individual cases of overtreatment such as unnecessary crowns, buildups or periodontal procedures can be costly on their own. At scale, those patterns can create substantial financial and operational impact for dental payers.

Beyond direct overpayments, FWA increases the administrative burden associated with auditing, investigating, appealing and recovering paid claims. That is one reason prepayment dental claim editing is so important: when inaccurate or inappropriate claims are identified before adjudication, plans can avoid pay-and-chase recovery, improve payment integrity, and reduce unnecessary provider abrasion.

Dental FWA claim patterns

Waste and abuse can take many different forms in dental billing and claims submission, and many of them can be addressed through stronger claim editing and expert review. Overtreatment, upcoding, repetitive add-on procedures, and suspect billing patterns can all undermine payment accuracy, trust, and patient well-being. Below are examples of FWA-related issues that advanced dental claim editing may help identify for deeper review:

• Add-on codes for crown procedures, which are categorized as abuse or fraud if the procedure was not performed.

• Upcoding, such as billing for a higher extraction code than warranted.

• Overtreatment, such as performing unnecessary fillings. This can be especially damaging for patients’ teeth, considering that putting a crown on a healthy tooth will naturally weaken it and shorten its longevity. Periodontal procedures such as root planing and scaling are another common example of overtreatment.

• Billing under different providers’ names within a multi-dentist practice in an attempt to sneak FWA past the dental claim system and claim editors.

An effective approach to dental payment integrity

While many dental plans already rely on a primary editor to catch duplicates or simple coding conflicts, advanced dental claim editing provide a critical next layer of protection. A second-pass prepayment review can evaluate claims against national and proprietary edits, clinical guidelines, member history, and plan-specific rules to identify suspect billing that may signal waste, abuse, or potential fraud—without overwhelming internal staff. This deeper level of review helps plans intervene earlier, before inappropriate claims are paid. For example, a national dental payer realized over $64 million in annual savings and a 3% incremental savings rate through Cotiviti’s enhanced dental claim review in a single year.

When suspect claims are flagged and validated before payment, plans can prevent incorrect reimbursement rather than pursuing recovery after the fact. This helps avoid the cost and friction of pay-and-chase while improving financial accuracy upfront. And when patterns suggest broader provider behavior concerns, postpay review and investigation can still play an important role in determining next steps, including provider outreach, education, or escalation in more serious cases. Cotiviti’s dental prepay and postpay solutions can inform each other by suggesting provider enhanced review and identifying new, emerging schemes.

Dental claim editing is further strengthened by professional review of documentation, x-rays and treatment history when needed to validate whether billing services are clinically appropriate and supported by plan guidelines.

Applying advanced clinical and coding algorithms to suspect claims help plans distinguish between routine billing variation and issues that warrant intervention, creating a more precise and defensible approach to combating FWA.

Detecting and stopping FWA through more precise dental claim editing and review helps dental plans reduce losses, protect member benefits, and discourage both inappropriate billing and treatment. With the right payment integrity strategy, plans can strengthen oversight, improve claim accuracy and create better outcomes for payers, providers and members alike.

Want to know more? Get in touch with our experts to learn how Dental Claim Accuracy can help strengthen payment integrity and identify suspect claims before payment.

About the author

Dr. Canfield works with Cotiviti’s prepayment leadership team and has been responsible for Dental Claim Accuracy operations since 2012, including overseeing a panel of professional consultants that perform clinical claim reviews. He also works as a clinical instructor at the University of Utah School of Dentistry and operates a private practice out of Salt Lake City, Utah. Dr. Canfield attended dental school at Creighton University, and has been practicing dentistry and reviewing dental insurance claims for more than 30 years.