Going to the dentist involves a certain level of trust. In a way, it’s not that different from taking your car to a mechanic: Most of us don’t have the expertise to evaluate the diagnosis.
While most dentists are ethical, it’s smart to remember that the degree on the wall isn’t a guarantee of honesty. Dental scams sink their teeth into unsuspecting patients every year, says James Quiggle, a spokesman for the Coalition Against Insurance Fraud.
“The most frequent dental scams are inflating claims, delivering worthless treatment that patients don’t need and billing insurers for phantom treatment that the dentist never delivered,” he says. “Dentists also may have a staffer do procedures that only a dentist is licensed to perform, yet bill as if the dentist had done the work.”
Leaving cavities in your finances
“Added up, these cons can mean big dollars for a dentist’s bank account,” Quiggle says.
The National Health Care Anti-Fraud Association estimates that financial losses due to health care fraud are in the tens of billions of dollars.
Less-than-honest dental practices may bill insurance providers for more expensive procedures than those actually performed — or fabricate charges entirely.
“From the patient’s perspective, these are things that can happen that they are not even aware of,” says dentist Dr. Katina Spadoni Morelli, dental director for dental benefits company Delta Dental of Illinois.
Beware of ‘upcoding’
Inflated claims, known as “upcoding” in the insurance industry, involve charging for a more expensive procedure than the one actually performed.
For example, Morelli says, a simple extraction might be upcoded to a more complicated one. A routine cleaning may be embellished to a pricier deep cleaning.
Con artists in white coats may even add procedures you never had.
“Check your explanation of benefits closely to make sure the bill reflects what procedures the dentist performed,” Quiggle says. “Did you really have X-rays or fillings replaced, or is that sneaky billing at work? Are the treatment dates accurate, and did you have as many procedures as the statement says?”
Another way some dentists might exaggerate a claim, Morelli says, is to break down a comprehensive procedure such as a root canal into its component parts and charge for each one, even though a single code could be used for the whole procedure.
Why should you, as a patient, care about insurance fraud? Isn’t that your insurance company’s responsibility?
“Larding your policy with unfounded billings can increase your premiums,” says Quiggle, of the Coalition Against Insurance Fraud, “and in extreme cases, max out your policy limits. This means the patient may be on the hook for excess billings.”
So, what can you do?
Patients need to be proactive, dentist Morelli says.
“Ask your dentist to pre-estimate the cost of treatments before any work is done,” she says, “because different dental plans may cover things differently.”
You also might want to ask for a treatment plan outlining exactly what procedures are needed and have the dentist review it with you, so you get an idea of what’s going on in your mouth.
Inquire about alternative treatments, because there’s almost always another way, Morelli says.
Some dental procedures are unsupported by scientific evidence and should be avoided, says Dr. Stephen Barrett, an M.D. and founder of Dental Watch, an online watchdog service.
“In the quackery line,” he says, “the clear winner is the removal of amalgam” — the mixture of liquid mercury and an alloy of silver, tin and copper that constitutes traditional “silver” fillings.
Removal may be worse than leaving them in
The Food and Drug Administration considers amalgam fillings safe, so there’s no need to have them ripped out. The FDA says clinical studies have found no link between the fillings and health problems in adults and children over the age of 6.
There is, however, potential risk in dental amalgam removal, Barrett says.
“When they drill the amalgam out, they also take out some of the healthy tooth around it,” he says, adding that if the tooth is not thick, the removal process can crack it.
“If a dentist says you need to have amalgams removed because they’re toxic, head for the exit,” Barrett says.
Other dental suggestions you might want to question, Barrett says, include balancing your bite with elaborate devices or putting crowns on healthy teeth. Unless you’re a model or an actor, you don’t need costly cosmetic work.
Morelli advises to be skeptical if a dentist recommends implants or bridgework where a simple removable appliance would do.
“Medical decisions are subjective by nature,” Quiggle says. “The diagnosis depends on the judgment of a trained doctor. This creates a tricky gray area between an honest diagnosis, a questionable one and an outright fraudulent diagnosis.”
Advice for parents in particular
Patients should be particularly leery of any recommendations of extreme surgery.
“Dentists have cut open people’s mouths with useless and botched surgery that left the patients disfigured and in pain,” Quiggle says. “The treatment of children by some large dental chains has been callous and uncaring. Kids have walked into the office for teeth cleaning and left bloody, with a mouth full of steel teeth.”
The Coalition Against Insurance Fraud advises parents to ask to remain in the treatment room while a child is in the dental chair. That way, you can “make sure your child is OK, the procedures are as painless as possible and only the promised treatments are done.”
You go to the dentist for routine services at an advertised price and, after a quick review, the dentist insists you need more costly work. You might easily feel that you’re being bullied into something you don’t want or need.
Don’t disregard your misgivings, Quiggle says.
“Medical bullying can be a problem,” Quiggle says. “It’s subtle. Dentists use their authority as the doctor in the white coat to talk a patient into an expensive and possibly painful surgery. It’s so easy to just say ‘yes’ to the impressive white coat. The result can be a world of discomfort for the patient and a financial windfall for the dentist.”
See what another dentist says
If you’re uncomfortable with a diagnosis or recommendations for extensive and expensive work, it’s wise to seek a 2nd opinion.
Barrett suggests getting one from a clinic at a dental school, where dentists may be more objective.
Keep accurate records of all appointments, Morelli stresses, and get all your paperwork in order before you undertake any kind of formal complaint.
“Dishonest dentists can doctor records or find an X-ray that will fit your condition,” she says. “The more evidence you have that the dentist wasn’t cooperative, the better case you have.”