Wednesday, May 19, 2021 (Kaiser News) – In 1993, Dr. David Silber, a dentist now practicing in Plano, Texas, was fired from the first dental clinic he worked for. It had been assigned to a patient that another dentist had scheduled for a crown preparation – a metal or porcelain coping for a broken or decayed tooth. However, Silber found nothing wrong with the tooth, so he sent the patient home.
He was fired later the same day. “Never fire a patient who is willing to pay the clinic money,” he told her.
Silber said what happened to him is still happening today, that some dentists who feel they are not getting enough insurance reimbursement – whether private insurance or Medicaid – have found ways improve their results. They offer products and procedures that a patient does not need or recommend more expensive treatment plans when less expensive options could accomplish the same.
The pressure is more intense now since the covid pandemic reduced traffic in dental offices. But while most dentists are ethical, the practice of using more cost-effective procedures, materials or devices is not new. In 2013, a Washington dentist writing in an American Dental Association publication lamented a “creative diagnostic” model. A 2019 dental cost study found big differences in the price of some services. He said that teeth whitening at the dentist, for example, is no more effective than the whitening strips you buy at the drugstore – and at least 10 times more expensive.
But sometimes dentists degenerate into outright fraud. A recent article in the Journal of Insurance Fraud in America makes it clear, “Medicaid fraud is the most lucrative business model in American dentistry today.”
Indeed, the ADA sees a problem. Dr. Dave Preble, senior vice president of the American Dental Association’s Institute of Practice, said, “Hundreds of thousands of dental procedures are performed safely and effectively on a daily basis.” But he cited a study by the National Health Care Anti-Fraud Association that between 3% and 10% of the $ 3.6 trillion Americans spend on health care each year is lost each year to fraud. . This represents up to $ 13 billion of the $ 136 billion Americans spend each year on dental care lost to dental fraud.
Silber said she saw a patient’s x-rays after seeing another dentist and was shocked to learn that she had had two crowns when she only needed a minor filling. She was told that the first crown was needed to treat decay in a tooth, and the second crown was needed to make the first crown fit better. “She only needed a little garnish. It should have cost him around $ 100, ”said Silber. “Instead, the dentist convinced her to replace two perfectly good teeth just so he could earn $ 2,400 from his insurance company.
The absorption of small private practices by companies, private equity buyouts or group practices over the past two decades has increased the emphasis on higher profits. “The executive at the top tells the dentists who work for them what procedures to push, like a chef tells their team of servers to push the daily special,” said Silber. “If a dentist refuses to comply, he is shown the door.”
One treatment that patients typically experience pressure on in corporate dental chains is quadrant scaling: an invasive procedure for cleaning teeth along the gum line, typically performed over three or four visits. While the procedure can be helpful if a patient is suffering from severe gum disease, it can erode gum tissue that cannot grow back. Dentists can charge anywhere from $ 800 to $ 1,200 for each procedure, while a standard cleaning only earns them around $ 100.
Dr Michael Davis, a dentist practicing in Santa Fe, New Mexico, said some dentists are looking for procedures for which Medicaid pays more. He explained that Medicaid paid three to six times more for nickel-chromium steel crowns than for standard fillings, so some dentists recommend these more cost-effective and invasive treatments to unsuspecting patients. “The fit of prefabricated steel crowns is unfavorable and may have shortcomings,” said Davis, “unethical dentists therefore target small children who will not notice the distorted fit until their permanent teeth come in. Game.”
Children who still have their baby teeth are prime targets for pulpotomies – the extraction of pulp from a tooth – whether they need it or not.
Unethical dentists also perform shortened versions of otherwise covered procedures for a patient, while charging the insurer the full amount – a practice known as upcoding.
Mini-implants, for example, can be easily upcoded. A standard dental implant is an artificial tooth root that dentists install to anchor a dental crown or bridge. A mini-implant, on the other hand, is like “a pushpin compared to a bolt,” said Dr. David Weinman, a practicing dentist in Buffalo, New York. In the past, mini-implants were only used to hold dentures in place, but since they are so much faster to install and cost the dentist up to 60% less than a regular implant, more and more of dentists have recommended them for a long time. solution eventually.
“We in the dental community are seeing a high failure rate when mini-implants are used where a regular implant is needed,” Weinman said, “but that hasn’t stopped some dentists from pushing them on. patients who do not know better.
Then there are horror stories of dentists gone wrong. In March, Dr. Mouhab Rizkallah, an orthodontist from Massachusetts, was sued by the state attorney general for deliberately keeping his patients in braces longer than medically necessary and for misleading billing for mouthguards. The complaint against him alleges that he asked his staff to buy plastic mouthguards from a discount store, even though he knew they would not fit patients’ teeth properly. Rizkallah then billed Medicaid $ 75 to $ 85 more than the retail price of each and was reimbursed over $ 1 million for the mouthguards alone, according to the lawsuit.
Other dentists have done much worse. After a video of Dr. Seth Lookhart, an Alaskan dentist, riding a hoverboard during a dental procedure, went viral, puzzled authorities discovered he had sedated almost all of his patients to cash in the reimbursements Medicaid pays. for general anesthesia. He was sentenced last year to 12 years in prison.
The Texas Dental Board revoked the license of Bethaniel Jefferson, a dentist who practiced in Houston, after discovering she was putting her patients at risk by unnecessarily administering general anesthesia to take advantage of the same insurance payments. She left a patient in a state of oxygen deprivation for so long that the child suffered severe brain damage.
Dr Scott Charmoli, a dentist in Wisconsin, has been charged with fraud after discovering he was using his drill to intentionally break patients’ teeth so he could bill the insurance company for crowns instead of fillings. The indictment alleges that he performed over $ 2 million in Crown proceedings between January 1, 2018 and August 7, 2019, or more than 80 fraudulent Crown proceedings per month.
Weinman said patients can always seek a second opinion – especially for expensive treatments – and that a dentist who seems hesitant when you say you want a second opinion is worrying. “A dentist who is confident in his abilities will have no problem verifying a diagnosis or treatment plan elsewhere,” he said.
Other red flags: Weinman says he is wary of any dentist who appears to be reading a script, or who pushes a treatment plan too hard or refuses to explain treatment options. “There may be several scientifically-based and evidence-based treatment plans available to a patient,” Weinman said, “and a good dentist is willing to explain your options, even those that may not be. also profitable. ”
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