It’s one thing to figure out how to find a good dentist your family loves…And an entirely different question to make sure your dentist’s office isn’t going to commit fraud at the expense of your checkbook.
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 abuse of patient care 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 dental 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 with too much work 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. There is inherently more variation in treatment standards, and it’s more difficult to pin down a procedure as truly unnecessary.
Here’s one example:
Lori visits her primary care physician and finds out that her A1c and blood sugar levels indicate a diagnosis of diabetes. She is prescribed a blood sugar-lowering medication, a prescription she’ll have to fill once a month. Lori’s insurance company recognizes this as a non-fraudulent transaction because the treatment lines up with the diagnosis, which was reached with specific data points (A1c and blood sugar levels).
Then, Lori goes to the dentist. She’s told she has signs of receding gums, gum disease, and several cavities that need filled. Lori takes it for granted that her dentist has her best interests at heart, so she goes forward with the four root canals and three fillings she’s prescribed, as well as a scaling and root planing.
Unfortunately, because her dental insurance only covers 50% of the cost (after she’s met a deductible), so Lori is stuck with a large bill after her many procedures. She has no idea that her records didn’t indicate such extreme treatment and that her insurance company would refuse to pay their portion of these costs.
This kind of example is one reason you should make sure you trust your dentist and s/he has a great reputation in the community.
The Way Dental Insurance Works
Before a patient first comes to a dental office, a member of the office staff will contact their dental insurance company to find out what’s covered under the dental plan. So before you walk in the room, a dentist has a list of everything he can bill for during your dental visit.
This leaves patients vulnerable to receive a treatment that may not be best for him or her, but is the most likely to be reimbursed by an insurance company.
Gray line between whether the tooth needs a filling or a root canal? A root canal and subsequent crown is more lucrative and easy to pass by an insurance company if the dentist claims the patient was in pain…Even if a filling would have done the job.
Pro tip: It’s a common “insider secret” that root canals are easier to pass through an insurance company than a filling. Plus, a root canal approval means you’re automatically approved for a crown.
In other words, recommending a root canal is an easy way to bill for the big-ticket crown…Even if the root canal isn’t the only viable option and a dental filling might do.
If you need a root canal, it’s not a bad idea to get a second opinion, just in case you could resolve the cavity with a less expensive and invasive procedure.
Medicare/Medicaid is notorious for requesting very little proof of the need for many types of procedures.
A reader who worked in a dental office once shared with me the story of her dentist who prescribed a rare procedure (called a “pulp cap”) every time he filled a tooth. Because most of the patients were covered by Medicaid, no questions were asked.
Except…That dentist didn’t actually need to (or even perform) this procedure. The only benefit was the added $26 per tooth on the bill sent to Medicaid—which is a tax-funded program.
HMO dental insurance plans work by paying “capitations” to dentists per person assigned to that provider. It’s a few dollars each month to the dentist, whether the patient shows up or not. To be profitable in this scenario, dentists need to diagnose and prescribe things beyond a standard cleaning. For some, this could result in the “development” of many dental problems that don’t actually exist.
In general, some types of dental insurance are a bit of a scam to many of the people who have it. It’s great for prevention, but don’t expect it to cover much of your major work.
If you’re looking into getting dental insurance through your workplace and you know you’ll probably need more than two standard cleanings a year, choose a PPO. This will pay for a larger percentage of treatments beyond prevention and doesn’t come with as many issues for you as a patient as HMOs or Medicare/Medicaid plans.
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 is 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.
The reality of how dental care works is that it’s up to the patient and the insurance company to make sure the right treatment plan is prescribed and implemented. With lower “dental IQ” than dental staff and providers, both you and your insurance company aren’t in a great place to make sure everything is above board.
4 Warning Signs of a Fraudulent Dentist
1. 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.
2. 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.
3. 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.
4. 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 how dental insurance pushes some dentists to bill specifically based on how they can make more money.
5. Not Showing You X-Rays
Does your dentist show you what s/he sees on your x-rays and point out the lesions and how they differ from healthy tooth structure? They should!
Looking over x-rays to talk through a treatment plan should be a group effort between the dentist and patient. Avoid working with a dentist who is hesitant to show you their findings on an x-ray.
How Can I Protect Myself Against Dentistry Fraud?
Beware of In-Network
Insurance plans put incentives in place for in-network dentists, like the capitations I described above. 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 Your Appointment Will Be
New patient appointments should take at least an hour and fifteen minutes to an hour and a half. Offices trying to cram in more patients than they can take might only keep you in the office 45 minutes.
Established patient appointments shouldn’t be as long, but you should still pay attention to how work is done. If you feel rushed, or that your providers aren’t taking enough time on your work, ask questions.
Even established patient cleanings should be 45-60 minutes long. If your cleaning only takes 20 minutes, start asking questions.
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 board websites offer an online search tool.
If you’re located in New York City, you might want to try a new tool called Smylen. They offer the option to quote your own price to get matched with a dentist you can afford. (Use coupon code ASKDENTIST for $10 off your first appointment booked through Smylen.)
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 can’t 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.
Be choosy: Pick the Best Dentist for You
Choosing the right dentist isn’t just a matter of not getting ripped off. The right dentist understands the mouth-body connection and enables 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.