Dental Fraud

A surprising number of dental patients on the wiki have left comments questioning billing procedures and diagnoses of their dentists. These comments are especially hard to sort out for a few reasons. For one, nobody likes going to the dentist, so it's easy to come away with negative feelings. As well, many college students may be handling their dental insurance for the first time and may be unaware of how it works. Nonetheless, if any sort of fraud is occuring, it benefits everyone (everyone with teeth, and everyone who pays insurance premiums) to root it out.

• Charges exceeding the amount the dentist submitted to the insurance company. This is a violation of the contract between an insurance company and the dental office. Most insurances expect the patient to pay a portion of the fee (co pay). Just because a dentist accepts a certain insurance does not necessarily mean they are contracted with that insurance company. If a dentist accepts an insurance, but is not contracted with them, then the dentist will submit their usual and customary fee (which can be higher than a contracted fee) to the insurance company. The insurance then pays the dentist whatever is dictated by the patent's plan and the patient is responsible to pay the difference.
  

• Diagnoses of cavities when none exist. (E.g. "you have eleven cavities"). This is particularly tricky because once a hole has been drilled, the evidence is gone. Also some dentists have different oppinions of what needs a filling. Some dentists prefer to watch very small cavities (in hopes that they dont spread) and some dentists like to restore very small cavities.
  

• Charging for multiple cleanings or only cleaning half of a patients mouth. Sometimes the dentist or hygienist needs more than one hour to remove all the tartar from your teeth. Most insurances only cover 1 cleaning every 6 months and the patient has to pay out of pocket for the second cleaning. This is very frustrating to the patient if it is not explained, however, it does not constitute fraud.
  

• Not releasing records or x-rays to the patient. It is customary for dental offices to charge a nominal fee (usually about $30) for the duplication of x-rays. Dentists are required to release these records upon writen request of the patient, they are not required to do so for free.

• Know what your insurance does and does not cover. (You are responsible for knowing what your insurance covers, not your dentist.)
  

• Get in touch with your insurance before paying any bill that you think is questionable. (Calling them afterwards is okay too.)
  

• Get a second opinion if you are suspicious of a diagnosis (most dental plans cover second opinions).

While we all want to stop dental fraud, it is important to keep in mind that any unfounded accusations can be very damaging to a potentially upstanding practitioner. For this reason, it is important to be absolutely certain a practice is fraudulent or unethical before leveling accusations.

UC Davis students are covered by Delta Dental. See their page on Dental Insurance Fraud (http://www.deltadentalca.org/enrollee/fraud.html). But keep in mind that this page discusses more than just insurance fraud.

Comments:

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2006-06-13 09:52:26   A common thing I've heard and been told about has to do with overcharging insurance, but not at the expense of the patient. I know for sure that wisdom teeth are a big issue as they have to be surgically removed. It costs a lot more to remove an impacted wisdom tooth than non-impacted ones. Most all insured people will pay the same amount no matter what (since it's so costly either way), but one of the most common practices is insurance being billed for 4 impacted wisdom teeth (if in reality it was only 2 or 3). As the patient pays a set amount either way, most people either don't notice, or don't care as insurance will cover it. (People might not care as a normal dentist can't perform this procedure, and you'll need to see a oral surgeon for this one time event). —ES

2007-04-15 09:35:52   Definitely get a second opinion if you're not sure about the diagnosis, but here's another thing to keep in mind — dentists differ in their treatment philosophy. Some want everything to be perfect, so if they see a tiny little problem, they will fix it. This sort of dentist will be the one who tells you that you need lots of fillings, etc. Other doctors are more willing to take a "wait and see" approach; sometimes small cavities or other problems don't amount to anything, or won't amount to anything for a long, long, time. Personally, I'd rather have the "wait and see" dentist than the "perfectionist" dentist, but the thing to do is to match the kind of dentist you want with the kind of dentist you have. This is the sort of thing you might ask about in your first visit with a new dentist: ask, "what is your treatment philosophy?" I had a perfectionist dentist once, and I will always wonder if I really needed the treatment that I received. —CovertProfessor

2008-02-06 11:09:40   When decay is shallow and in the enamel only it is reversable. Ions from your saliva can absorb into an early lesion and remineralize the affected enamel. This generally only works on the smooth surfaces of the teeth (like in between the teeth and on the sides). When decay is very shallow on the chewing surfaces of the teeth it often continues to spread despite all best efforts to keep the areas clean. This is because all the pits and grooves of the teeth harbor many bacteria and are difficult if not impossible to clean. Access to decay in the pits and grooves of the teeth is often straight forward; therefore, removal of only the decay with a very small preparation (hole)can be achieved. This is often referred to as "microdentistry". So if your dentist tells you you have cavities ask if any of them are possible to remineralize. Remineralization can be assisted by fluoride mouthrinses and xylitol chewing gum. Xylitol is a natural sweetener that inhibits bacteria from sticking to the teeth. The most important aspect of remineralization is preventing acid attack, so brush and floss daily (flossing is ussually the key) and avoid frequent sugar/charbohydrate snacks. Once decay has grown past the enamel and is into the dentin (the inner part of the tooth) a filling is necessary. If you are attepmting to remineralize some very suspicous areas of decay your dentist may want to take x-rays more frequently to make sure they dont spread too deep. If anyone has questions about dentistry, dental materials, or preventive dentistry please go to dental questions
I will answer any questions people may have. - Dagon H.C. Jones DDS

—DagonJones

2008-05-20 20:43:48   On top of what Dr. Dagon Jones has said, you can get Xylitol at Kim's Mart with the brand by Lotte or you can head over to the store next door, I think it's Davis Health Foods? The name escapes me now, but you can get Spry gum with Xylitol right there! —CalvinCheng

2010-01-29 22:49:36   My husband took my 5 yr old in for 2 fillings in her baby teeth (Tooth#A-O and J-O). He didn't see a drill or a shot just a "nail polish like brush" the dentist used on her teeth. Sounds like sealants, but I was charged $152 for each cavity. Her appt was at 0800 and he was done and checking out and leaving with her at 0823 am. I have changed offices and pursued this, but seems like the new dentist is covering for her because he didn't acknowledge that there were restorations there, but when I filed a grievance with Delta Dental, he sent a letter stating he looked at her teeth and the restorations are there. I spoke with that office concerning this issue over the course of two weeks and not once did he tell me that they were there. When I questioned the original dentist and told her my husband was there the whole time and didn't see a shot or drill, she told me that maybe she did it so fast that he didn't see it. Suspicious? She has also sent documentation that she gave her lidocaine, but my husband saw none of it. In fact, he was waiting for her to get the shot because he knew she would freak out. Also discoverd that my 8 yr old had sealants put on tooth 19 and 30 and at the next visit with the new dentist, he said it looked like nothing was ever there.—MMG

2010-02-09 10:43:37   This last comment is a tricky one to evaluate. I cant say what happened one way or the other but it is important to understand that a filling can be done without a shot. Anesthetic is not always necessary when doing a small filling. A drill or similar instrument is needed to remove the decay (otherwise it is considered a sealant, not a filling). Instruments other than a drill can be used such as a microblaster (like a small sandblaster) or a laser, both of these are uncommon and not frequently used on kids. Also many filling materials and sealants are tooth colored so it can be very hard to notice them on the teeth once they are done. —DagonJones

2010-02-11 20:45:17   I guess my main point was that I point blank asked the dentist if she gave her a shot with a needle and she said yes. My husband did not see this nor did he see or hear any type of drilling. This is where I believe she is lying. I feel she isn't being honest with me given the circumstances that my husband witnessed and the use of the sealant brush. My husband also works with someone whose friend left that office after she was told to bill for services not rendered. She refused so she quit. When my husband returned to work that day, he expressed how surprised he was that he was in and out of there. He also mentioned that filling cavities had changed a lot since he had them because there was no drilling or shot. This is what raised my suspicions that it wasn't cavities that were filled, but sealants done. My complaint has more to do with the ethics since I spoke to the dentist myself and to tell me she did use a needle and did it so fast that he maybe didn't see it just doesn't seem reasonable. They sent me the notes after I requested them (I received them a week later) and it says right on there that she received a shot and that a moderate sized preparation was done. From what I've read on the composite fillings, they seem to take a little longer to do so she is awful speedy if she got that all done for two cavities in 15-18 minutes, especially on a child who has never had dental work done. I did submit a grievance to the dental board in my state. I am hoping they will investigate and help me settle this once and for all. It's hard to let go of it if they are committing fraud because I obviously would not be the only one that has had this happen at that office. Thank you for your comments. —MMG

Your concerns are valid and I understand your suspicion. The situation you are describing sounds fishy. It is terrible to feel taken advantage of, especially when it involves your children. I hope you eventually get some answers that make sense.dagonjones