By Daryl Austin
Wednesday, May 19, 2021 (Kaiser News) – In 1993, Dr. David Silber, a dentist practicing in Plano, Texas today, was fired from the first dental clinic he worked for. He had been assigned to a patient another dentist had scheduled for a crown preparation – a metal or porcelain cap for a broken or decayed tooth. However, Silber found nothing wrong with the tooth and sent the patient home.
He was fired later that day. “Never send a patient away who is willing to pay the clinic’s money,” he was told.
Silber said what happened to him back then is still happening today that some dentists who don’t believe they’re getting enough of insurance reimbursement – whether private insurance or Medicaid – have found ways to increase their bottom line. They promote products and procedures that a patient does not need or recommend more expensive treatment plans when lower-cost options may do the same.
The pressure is now stronger as the covid pandemic restricted traffic in dental offices. While most dentists are ethically correct, the practice of using more profitable procedures, materials, or equipment is not new. In 2013, a Washington dentist who wrote in an American Dental Association publication complained of a pattern of “creative diagnosis.” A 2019 study of dental costs found wide price differences for certain services. Tooth whitening in the dental practice, for example, is no more effective than whitening strips that you buy in the drugstore – and at least ten times more expensive.
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But sometimes dentists escalate into downright fraud. A recent article in the Journal of Insurance Fraud in America made it clear: “Medicaid fraud is the most lucrative business model in US dentistry today.”
Indeed, the ADA sees a problem. Dr. Dave Preble, senior vice president of the American Dental Association’s Practice Institute, said, “Hundreds of thousands of dental procedures are performed safely and effectively every day.” However, he cited a study by the National Health Care Anti-Fraud Association that found between 3% and 10% of the $ 3.6 trillion Americans spend annually on health care is lost each year to fraud. That’s $ 13 billion of the $ 136 billion Americans spend annually on dental care lost to dental fraud.
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Silber said he saw a patient’s x-rays after seeing another dentist and was shocked to learn that she put two crowns in when she only needed a small filling. She was told that the first crown was necessary to treat tooth decay in a tooth and the second crown was necessary to make the first crown fit better. “All she needed was a little filling. It should have cost her about $ 100, “said Silber. “Instead, the dentist convinced her to replace two good teeth so he could make $ 2,400 with her insurance company.”
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Corporate adoption of small private practices, private equity buyouts, or group practices over the past two decades has increased the focus on higher profits. “The top manager tells the dentists who work for them which procedures are to be pushed, like a cook tells their waiters to push the dish of the day,” said Silber. “If a dentist refuses to comply, they’ll be shown the door.”
One treatment that often puts pressure on patients to undergo in corporate tooth chains is quadrant scaling: an invasive tooth cleaning procedure along the gumline that is usually performed over three or four visits. While the procedure can be helpful if a patient has 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 clean only gets them around $ 100.
Dr. Michael Davis, a dentist practicing in Santa Fe, New Mexico, said some dentists are looking for procedures that Medicaid pays more for. He explained that Medicaid pays three to six times more for nickel-chrome steel crowns than it does for standard fillings. Some dentists recommend these more profitable and invasive treatments to unsuspecting patients. “Pre-fabricated steel crowns fit poorly and can have gaps,” said Davis. “Unethical dentists target young children who don’t notice the misshapen fit until their permanent teeth have penetrated.”
Children who still have their milk teeth are primary targets for pulpotomies – the removal of the pulp of a tooth – whether they need it or not.
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Unethical dentists also perform shortcut 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 easily be up-coded. A standard dental implant is an artificial tooth root that dentists install to anchor a tooth crown or bridge. In contrast, a mini-implant is like a thumbtack compared to a bolt, said Dr. David Weinman, a dentist practicing in Buffalo, New York. In the past, mini-implants were only used to hold dentures in place. However, because they are so much quicker to install and cost the dentist up to 60% less than a normal implant, more dentists recommend them as term solution long term implants.
“We in the dental industry see a high failure rate when mini-implants are used where a regular implant is needed,” said Weinman. “But that hasn’t stopped some dentists from putting it on patients who don’t know any better.”
Then there are horror stories of dentists going bad. In March, Dr. Mouhab Rizkallah, a Massachusetts orthodontist, is sued by the Attorney General for deliberately keeping his patients in braces for longer than medically necessary and misleadingly billing mouthguards. The complaint against him alleges that he directed his employees to buy plastic mouthguards from a discount store, even though he knew they would not fit the patients’ teeth properly. Rizkallah then billed Medicaid $ 75 to $ 85 more than the retail price for each and received more than $ 1 million for the mouthguards alone, according to the lawsuit.
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Other dentists have done far worse. After watching a video from Dr. Seth Lookhart, an Alaska dentist who went viral on a hoverboard during a dental procedure, was fascinated authorities to discover that he had sedated almost all of his patients in order to benefit from the reimbursements Medicaid pays for general anesthesia. He was sentenced to 12 years in prison last year.
The Texas Dental Board revoked the license of Bethaniel Jefferson, a dentist who practiced in Houston, after finding that she was putting her patients at risk from unnecessary general anesthesia, to receive the same insurance payments. It left a patient in a deoxygenated state for so long that the child suffered severe brain damage.
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Dr. Scott Charmoli, a Wisconsin dentist, was charged with fraud after it was found he used his drill on purpose to break patients’ teeth so he could charge the insurance company for crowns instead of fillings. The indictment alleges that he conducted more than $ 2 million worth of crown proceedings between January 1, 2018 and August 7, 2019 – the equivalent of more than 80 fraudulent crown proceedings per month.
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Weinman said that patients can always get a second opinion – especially with expensive treatments – and that a dentist who hesitates when they say they want a second opinion is worrying. “A dentist who is confident in their skills has no problem reviewing a diagnosis or treatment plan elsewhere,” he said.
Other red flags: Weinman should be wary of any dentist who appears to be reading from a script, or who is over-advancing a treatment plan, or who refuses to explain treatment options. “There may be multiple science-based, evidence-based treatment plans available to a patient,” Weinman said. “A good dentist is ready to explain your options, including those that may not be as profitable.”
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