Dr. Patel had done everything right. It had taken her three years to pass the NDEB (National Dental Examining Board) equivalency process to be able to practice as a dentist in Canada. She had left her home in India and was happy to now live and be able to work in the career she loved.

She had practiced as an associate for two years and had finally been able to open her own practice at the age of 33. She was proud of her new life, her husband and two kids, and the home they had just bought. The loans she had were finally going to start being paid off. She had a great office team, was proud of her numbers, and proud of how smoothly everything ran.

She had no idea that “smoothly” was part of the problem…

Every morning, during the team huddle and treatment plan reviews, procedure codes were pre-selected to speed up checkout. Every week, claims went out before providers reviewed them for accuracy. Every month, the numbers looked great and no one questioned them.

Until an insurance carrier did.

It isn’t one big thing. It never is.
It’s the small, daily habits that feel like efficiency but can amount to abuse of dental insurance and dental fee guides.

Billing for a complete examination when technically a recall exam was performed because the patient hadn’t been in for a while and “it felt like more work.” Staff resending a rejected claim with a different code because they’d seen it done at the last office and it always went through.

None of it felt wrong at the time. It was just how things were done.

But insurance carriers don’t audit or investigate single appointments. They observe patterns in billing analytics, and Dr. Patel’s patterns had been quietly building a case for some time.

The Hidden Risks in Everyday Habits

• Coding out of habit: Billing a higher procedure code because the lower one “doesn’t cover enough.” Common. Flaggable. Your liability.
• Submitting before documentation is complete: The claim goes out Friday, the chart note gets filled on Monday and may not fully support the submitted claim.
• Resending rejected claims without clinical input: Changing a code to get a claim through is not a billing workaround. It’s a fraudulent submission under your provider number.
• Billing by assumption: “The doctor always does X with Y, so I just add it.” Without clinical verification, every one of those claims is unsupported.
• Frequency creep: Your practice slowly bills certain codes more and more often. No single claim is wrong, but the pattern puts you in the top percentile for your region. That’s a flag.

Dr. Patel didn’t necessarily do any of these things intentionally. But they happened in her practice, under her name, with her provider number.

And that’s all that mattered to the insurance company.

“Every insurance or regulatory audit I have reviewed in my career starts with a profile. A dentist or office that is an outlier, whether from a single code being used or a series of codes and processes that are flags. Simple repetitive procedures that can lead to an investigation.”
– Dr. Ali Kapasi, DDS | Dental Consultant & Forensic Billing Specialist

Your Responsibility

REMEMBER: You are responsible for every claim submitted under your provider number. Every single one. Not your receptionist. Not your office manager. You.

At Dr. Ali Kapasi Dental Consulting, we work with practice owners and those looking to purchase a practice to audit what’s already happening and build the oversight systems and training.

• Billing reviews that surface patterns you can’t see
• Claims integrity audits before an insurer knocks on your door
• Compliance frameworks your team understands and follows
• Real guidance from a dentist who has sat on both sides of the audit table