I’ll never forget the long nights I spent poring over x-rays and charts in order to assist the lawyer paying me as an expert witness on a case of fraudulent dentistry.
The case was an elderly mother against a dentist in practice for 20 years. The dentist had sold his practice to another dentist, inflating the margins and inflating the value of the practice with procedures that people didn’t need.
I had seen this plenty of times before, but this one was egregious. It gave me a sick feeling in my stomach.
Fraudulent dentistry doesn’t go on in the majority of practices, but I still see it far too often.
The dentist you have can make a huge impact on your life – positive or negative.
A good dentist is your partner in health who works with you to optimize your well-being and prevent disease. The right oral health partner for you is the dentist who is wholly concerned with your overall health and not the health of her pocketbook.
The wrong dentist can wreak havoc on your mouth and do permanent damage by doing too much work that you don’t need.
So how do you differentiate between the two?
This is my advice on how to find an honest and ethical dental practice that will be your partner in health for a lifetime.
How Common Is Fraudulent Dentistry?
The vast majority of dentists are honest; for one thing, building a successful practice takes years of hard work, and it’s exceedingly foolish to risk losing it.
But, like many industries, a potential for taking shortcuts for financial gain will attract a small but not insignificant number of people who feel they can take advantage of others.
The Coalition Against Insurance Fraud describes the problem as involving “a small but disturbing number of dentists.”
Why Is Dentistry Vulnerable to Fraud?
There are certain aspects of dentistry that leave the profession more vulnerable to fraud than, say, the medical profession:
The Subjective Nature of Dental Diagnosis
The decision as to whether you need a dental treatment is often in a gray area. One dentist will say one thing, one will say another. This is normal, and it’s to be expected. But it means that the usual signs of insurance fraud – a practitioner prescribing more procedures than his or her colleagues – are more difficult to detect, because there’s more variation, and it’s more difficult to really pin down a procedure as unnecessary.
The Way Dental Insurance Works
Dental insurance and medical insurance are very different. Dental insurance covers a maximum of around $2,000 per year — the exact opposite of medical insurance, which caps the amount you have to pay out of pocket so that you don’t go broke if you need, say, coronary bypass surgery.
This makes dental insurance more profitable than medical because it’s predictable. Since it’s predictable, there’s less scrutiny over every charge. Since pay out is capped at no more than $2,000 per person, the dental insurance companies can create an algorithm that reliably lets them know what profit will be. Medical insurance companies, on the other hand, scrutinize everything because there’s no cap on what they might have to pay out on for, say, a massive brain surgery.
Lack of Oversight
For a medical procedure, any diagnosis will be subject to a lot of review, from doctors to nurses to specialists to other clinic or hospital staff. In dentistry, the only people “in the know” are you (who presumably are not an expert), the staff who work directly for the dentist, and the dentist him or herself. There’s much more potential for abuse when there’s less chance of being challenged.
Perverse Incentives by Insurance Companies
Often, it works like this: A dentist will agree to be “in-network” in exchange for a steady stream of patients from the insurance company. They get paid by the insurance company “by the head” instead of according to how much treatment they actually provide. If the insurance company agrees to send the dentist 12,000 patients per month, and the dentist gets $8 per head per month (this is called a capitation plan) then that’s $96,000 per month, regardless of what their costs are. See the problem?
So the incentive is to pocket as much of the cash as possible by reducing overhead. To reduce overhead, they’ll push off work that needs to be done in their patients and then promote treatments that aren’t covered by insurance.
With perverse incentives like these, how much is that in-network dentist or that free cleaning actually costing you and your family — both money-wise and health-wise?
What Are the Warning Signs of a Fraudulent Dentist?
Urgency Without Details
If your dentist tells you that you need to have a procedure done immediately, ask why. A dentist who is vague about this could be pressuring you into a procedure.
Heavy Work That Comes Out of the Blue
The number one warning sign is when you sit in a dentist’s chair for the first time and are told you need a bunch of procedures of a type or quantity you’ve never needed before. Trust your gut on this one. If you’ve never had a cavity in your life and at your first appointment with a new dentist, she tells you that you need 12 fillings, that’s a red flag.
Deals That Are Too Good to Be True
A common pattern I see is dentists that use a deeply discounted or even free cleaning or checkup to get you in the door, and once you’re in the chair, hit you with thousands of dollars of work that you don’t need.
Diagnosing a Lot of Procedures Not Covered By Insurance
A lot of treatment that isn’t covered by insurance is a red flag. Read the section above on perverse incentives given to in-network dentists.
How Can I Protect Myself Against Dentistry Fraud?
Beware of In-Network
Insurance plans put perverse incentives in place for in-network dentists. When dentists become part of these networks, they agree to extremely low reimbursements for cleanings and exams, in exchange for a steady stream of patients. To make up for it, some dentists will perform procedures that have a significant patient portion or heavily promote cosmetic work as being necessary.
Choose a Dentist Based on Referrals — Not Who Your Insurance Company Tells You to See
As with any other profession, the way to maximize your chances of having a good experience is by relying on the advice of others who’ve had a good experience. If you’re new to the area, you can always ask for a recommendation from your local dental society or health professional. Don’t rely on the fact that a dentist is covered by your insurance plan; this is not the same thing as a referral. The best referrals come from friends, family, and co-workers that have had procedures other than teeth cleanings at the dentist.
Stay Away from Practices That Advertise
Heavy advertising and deep discounts are come-ons. Billboards and TV advertisements should also make you wary. Advertising-driven offices often use deals as a way to get patients in the door and then pressure them to accept an expensive treatment plan. I call this Wall Street Dentistry. Often, they’re corporate-owned chains, like Aspen Dental. These chains are like dental mills. They give you the free (quick) cleaning, the free cursory exam, and then tell you that you need $4,000 worth of unnecessary dental work. Many of these franchise-based practices you see in ads rely on a quota-based work model. These sorts of incentives lead dentists to err on the side of extra treatment.
Look for a Name on the Door
Choose a clinic where the dentist has his or her name on the door, which often implies that personal ownership and that, reputation-wise, they have a lot to lose because their name is on the line (or the door). It’s easy to hide behind a sign that says “Big Smiles Dental.”
Ask for a Second Opinion
Even just observing a dentist’s reaction to being told you’d like a second opinion can be telling; if they truly have nothing to hide, they won’t discourage you.
Ask How Long a Cleaning Takes
It’s impossible to complete a thorough cleaning in less than an hour, including 10 minutes of education. If the hygienist uses an ultrasonic cleaner, that device should be used alongside hand scaling. It is physically impossible to do a good cleaning in less than a full hour, unless you’re missing some teeth. Anything less means they’re doubling the productivity of the hygienist.
Price Check and Do Your Research
Tooth pain is a great motivator. When you’re in pain, you’re often willing to fork over any sum to find relief. But take steps to make sure you’re paying market rate. First check the Healthcare Blue Book, a respected online tool that provides a fair price for thousands of medical and dental procedures in your ZIP code. And don’t be shy to call around to other dentists in your area to price shop. Ask friends and neighbors for recommendations, and check out any potential dentist with your state’s dental board to ensure he or she is licensed and to find out if any disciplinary action has been taken. Most offer an online search tool.
Be Skeptical of a New Dentist That Prescribes a Ton of Treatment
A common pattern of fraud is a patient visiting a new dentist for a checkup and being told he or she needs a ton of work. Of course, if you’re in lots of pain, or haven’t been to the dentist in years, this might not apply.
Trust Your Gut
If you have a bad feeling, walk away. Dentists are there to help you, they should not be pressuring you. You can always come back if you decide you are overreacting, but with something that can potentially put you out of pocket for a large sum of money, it’s best to trust your instincts.
Ask About Loupes
No dentist should be practicing without loupes, which are little surgical telescopes that magnify. It has nothing to do with ailing eyesight, it’s the magnification factor that lets you see more than you could with 20/20 vision. If you can’t see it, you cant treat it! Ask your dentist if she or he uses 2.5x or 4.4x power on her loupes. The higher the better! An LED spotlight on the forehead is even better.
Check out my guide to how to find a great dentist.
Choosing the right dentist isn’t just a matter of not getting ripped off. The right dentist understands the oral health systemic connection and helps you square your life curve, enabling you to have a healthier, longer life by maximizing your oral health.
Do not underestimate the value of a dentist who is your partner in health — it will extend your and your family’s lifespan, quality of life, and well-being.
Mark Burhenne DDS
What are your tips? Let me know in the comments below!