DentaChain: A Provenance-Verified Smart Contract System for Dental Billing Fraud Prevention

Abstract

Dental billing fraud costs the United States an estimated $5.2 billion to $17.4 billion annually, yet detection relies entirely on retrospective rule-based auditing that leaves the real-time claimsubmission window unaddressed. The laboratory-to-clinic workflow governing prosthetic manufacturing remains paper-based, dispute-prone, and disconnected from insurance adjudication. This paper presents DentaChain, a permissioned blockchain framework chaining dental laboratory workflow management directly to insurance claim verification. Three Solidity smart contracts deployed on Hyperledger Besu automate milestone-driven prosthetic manufacturing with escrowbased payment release, enforce a causal provenance chain that structurally eliminates phantom billing prior to any machine learning inference, and maintain an immutable, regulator-accessible compliance ledger. A dual-model machine learning pipeline completes the system: a Random Forest classifier with synthetic minority oversampling predicts prosthetic defect risk before manufacturing begins (AUC = 0.991, recall = 0.949), while a Random Forest and Isolation Forest ensemble detects claims across four fraud typologies in real time (AUC = 0.986, recall = 0.927), evaluated under partial-signal fraud injection for conservative performance estimates. At the recommended operating threshold, 95.5% of claims are auto-approved, reducing adjudicator workload. A synthetic dataset of 50,000 Current Dental Terminology (CDT) claims and 12,000 laboratory orders is released publicly to support reproducibility.