Fraudulent billing

Sept. 1, 2005
Dear Dianne, As a dental hygienist for nearly 30 years, I would like to address how much dental insurance companies are being overcharged.

Dear Dianne,

As a dental hygienist for nearly 30 years, I would like to address how much dental insurance companies are being overcharged. It has been my experience that many dentists lack integrity and trust, and bill for procedures that are not actually performed on the patient. Fraud is being committed by the office manager and/or receptionist.

For example, application of a desensitizing agent after scaling and root planing is rarely, if ever, done. However, dentists often charge the insurance company for each quadrant scaled. Sometimes patients want restorations that are considered cosmetic, and insurance companies will not authorize such procedures. Dentists submit narratives stating that “leaking” or “broken margins” are present. There is also the ever popular “cracked tooth syndrome” and “failing” restorations and crowns.

Pre-authorization for build-ups under crowns is another popular overused code. If it is approved (which it usually is), it is done whether it is really needed or not.

Another great little scam is taking four bitewing radiographs at one appointment and then having the patient back for a full mouth series of radiographs. The bitewings are included in the full mouth series, but, if charged out separately, insurance will pay them as separate procedures.

There are many other examples, but these seem to be the most frequently used fraudulent insurance billing procedures. By no means am I presenting this letter as a dentist. I am not a dentist, and I do not have a dentist’s education or skills. But dentists have told me that this is how they practice, this is what is done, and that anyone who does not take advantage of these loopholes is a fool. Of course, I have also been told that a monkey could be trained to perform dental hygiene duties for free.

It seems to be all about the money, doesn’t it?
Concerned Hygienist

Dear Concerned,

It is unfortunate that your work experience has been with doctors who have shady ethics. If my bosses were as unethical as you describe, I’d be disillusioned, too. Further, if a doctor made that asinine comment to me about monkeys, I’d probably agree and say I know a few baboons that do dentistry.

Desensitizing after root planing and scaling is a step that is often omitted or never done. But it is a very effective way to help control post scaling sensitivity. Once calculus has been removed from the root surfaces of teeth that have not seen the light of day for a long time, the patient is almost sure to have sensitivity. Fluoride varnish, properly applied, can virtually eliminate that unpleasant side effect of scaling. However, I’d like to point out that the CDT 2005 codes are different for application of fluoride varnish, depending on why it is used. If the fluoride varnish is used for caries prevention, the proper codes are the same as for topical fluoride application (D1203, D1204). However, if fluoride varnish is used for desensitizing purposes, the correct code is D9910.

Further, just because the ADA provides a code does not mean an insurance company will pay on that code. Some companies will pay for fluoride varnish when it is applied for caries control but not when it is used for desensitizing purposes. Go figure. The important thing is that documentation in the chart should reflect why the varnish is applied.

It should also be pointed out that fluoride varnish has been approved by the FDA in the United States for sensitivity control but not caries control. European countries, though, have been using the same product for caries control with great succes for many years.

I do not know how rampant fraud is in the dental profession, but my 30 years of experiences have been overwhelmingly positive. I can honestly say that of all the doctors I have worked with, both as employers and consulting clients, there has been only one I would consider unethical. The problems were in over diagnosing and submitting false treatment dates to get better reimbursement.

There’s a certain amount of indignation between dentists and insurance companies in general, because insurance companies have usurped much of the control in fee setting. Doctors tire of hearing, “Just do what the insurance will pay, doc.” Many have allowed their practices to become insurance-driven and have bowed to the directives of third party payers. In these situations, it is not unusual for the doctor to find “creative” ways to beat the system.

However, dishonesty has an effect I saw expressed on a poster that says, “There’s a ripple effect in all that we do. What you do touches me, and what I do touches you.”

Most doctors have no idea that dishonesty costs them the respect of staff members, which leads to turnover. A doctor may feel that dishonesty is acceptable because it is for the patient’s benefit. He/she simply feels it is all right to “bend the law” under the guise of helping patients.

Doctors who engage in dishonest practices are not only unethical, but downright unwise. All it takes is one disgruntled staff member or patient to report the crime to the police or state dental board and the doctor is toast. I heard about a dentist who was censured by the dental board for “over diagnosis.” He was ordered to refund some money and take continuing dental education classes. While not pleased with the outcome, he mistakenly believed that his actions were inconsequential. His largest third party provider heard of the decision and three months later, he received a letter that terminated his services. Overnight, 23 percent of his business was gone! He didn’t know that all insurance company settlements from malpractice proceedings are reported to the National Practitioner Data Bank, and third party providers monitor the NPDB.

Here are the violations that trigger third party provider intervention:

• Revocation, suspension or restriction of a license

• Fraud

• False statements

• Over diagnosis

• Failure to diagnose

• Billing irregularities

• Aiding and abetting (allowing non-licensed personnel to perform functions for which a license/permit is needed)

• Patient abandonment

There is no excuse for dishonesty. Whether or not a patient has company-sponsored dental benefits does not preclude the doctor from being ethical, honest, and moral.

When people do wrong over and over, they become desensitized to the wrong. Since these dishonest and unethical business practices have become ingrained, I doubt that you could say anything to change things. If you tell the doctor you don’t approve or you’re uncomfortable with what’s going on, you’ll only make him/her angry or indignant. No matter what you say, you cannot change the doctor’s heart.

Crooks are in every profession. I think that most doctors practice with integrity and impeccable ethical standards when it comes to patient care. However, I am aware that some choose to color outside the lines of honesty. They will have to answer for those choices at some time if you believe, like I do, that what goes around comes around.

Most states allow anonymous tips to state dental boards for unethical conduct. But remember the board is a civil entity. Fraud is a criminal matter. The doctor’s problem will first be with the state. If convicted of a crime involving moral turpitude, the board will certainly sanction him/her. If you report the doctor to the insurance company that is being defrauded, you may be asked to furnish thorough documentation of the alleged fraud. Insurance companies are always on the lookout for irregular coding/billing procedures. Be prepared to lose your job and possibly be blacklisted from future local employment if you’re ever revealed as a whistleblower. Make sure you think it through, count the costs, and settle it in your own heart and mind.

When a dentist becomes indiscreet with his/her dishonesty, there’s trouble on the horizon. The old saying, “Give a dog enough rope and he will hang himself” applies here. It is just a matter of time before the doctor hangs him/herself. He/she is unethical, immoral, and dishonest. How could anybody respect a boss like that?

It might be all about the money, but who is the real fool here? I believe I read somewhere that a fool and his money are soon parted.

Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or email [email protected]. Visit her Web site at