By Daryl Austin. Originally published at Kaiser Health News.
In 1993, Dr. David Silber, a dentist now practicing in Plano, Texas, was fired from the first dental clinic he worked for. He’d 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, so he sent the patient home.
He was fired later the same day. “Never send a patient away who’s willing to pay the clinic money,” he was told.
Silber said what happened to him then still happens today, that some dentists who don’t think they receive enough from insurance reimbursement — whether private insurance or Medicaid — have figured out ways to boost their bottom lines. They push products and procedures a patient doesn’t need or recommend higher-cost treatment plans when less expensive options might accomplish the same thing.
The pressure is more intense now since the covid pandemic cut traffic into dentists’ offices. But while most dentists are ethical, the practice of going with more profitable procedures, materials or appliances is not new. In 2013, a Washington dentist writing in an American Dental Association publication lamented a pattern of “creative diagnosis.” A 2019 study of dental costs found wide differences in the price of certain services. It said teeth whitening at the dentist’s office, for example, is no more effective than whitening strips one buys at the drugstore — and at least 10 times more expensive.
But sometimes dentists escalate to outright fraud. A recent article in the Journal of Insurance Fraud in America put it plainly: “Medicaid fraud is the most lucrative business model in U.S. 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 on a daily basis.” But he cited a study from the National Health Care Anti-Fraud Association that says between 3% and 10% of the $3.6 trillion Americans spend annually on health care is lost to fraud each year. That’s as much as $13 billion of the $136 billion Americans spend annually on dental care lost to dental fraud.
Silber said he saw the X-rays of one patient after she’d seen another dentist and was shocked to learn she’d had two crowns put in when she needed only one minor filling. She was told the first crown was necessary to treat decay in one tooth, and the second crown was needed to make the first crown fit better. “She only needed one small filling. It should have cost her $100 or so,” Silber said. “Instead, the dentist convinced her to replace two perfectly good teeth just so he could make $2,400 from her insurance company.”
The absorption of small private practices by corporations, private-equity buyouts or group practices over the past two decades has increased the emphasis on higher profits. “The executive at the top tells the dentists working for them which procedures to push, like a chef tells their team of waiters to push the daily special,” Silber said. “If a dentist refuses to comply, they’re shown the door.”
One treatment patients are commonly pressured to undergo in corporate dental chains is quadrant scaling: an invasive teeth-cleaning procedure along the gum line, usually done over three or four visits. While the procedure can be helpful if a patient suffers from severe gum disease, it can erode gum tissue that cannot grow back. Dentists can charge between $800 and $1,200 for each procedure, while a standard cleaning nets them only about $100.
Dr. Michael Davis, a dentist practicing in Santa Fe, New Mexico, said some dentists look for procedures for which Medicaid pays more. He explained that Medicaid pays three to six times more for nickel-chromium steel crowns than for standard fillings, so some dentists recommend those more profitable and invasive treatments to unsuspecting patients. “The fit of premanufactured steel crowns is unfavorable and can show gaps,” Davis said, “so unethical dentists target little children who won’t notice the misshapen fit until their permanent teeth come in.”
Children who still have their baby teeth are prime targets for pulpotomies — the removal of the pulp of a tooth — whether they need them or not.
Unethical dentists also perform shortcut versions of otherwise covered procedures for a patient, while billing the insurer for the full amount — a practice known as upcoding.
Mini-implants, for example, can be easily upcoded. A standard dental implant is an artificial tooth root that dentists install to anchor a dental crown or bridge. A mini-implant, by contrast, 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 used only to hold dentures in place, but because they are so much quicker to install and cost the dentist as much as 60% less than a regular implant, more dentists have been recommending them as a long-term solution.
“We in the dental community see a high failure rate when mini-implants are used where a regular implant is needed,” Weinman said, “but that hasn’t stopped some dentists from pushing them on patients who don’t know better.”
Then there are horror stories of dentists gone bad. In March, Dr. Mouhab Rizkallah, a Massachusetts orthodontist, was sued by the state’s attorney general for deliberately keeping his patients in braces longer than medically necessary and for deceptive billing for mouthguards. The complaint against him alleges he instructed his staff to buy plastic mouthguards at a discount store even though he knew they wouldn’t fit the patients’ teeth properly. Rizkallah then billed Medicaid $75 to $85 more than the retail price for each one and was reimbursed more than $1 million for the mouthguards alone, according to the lawsuit.
Other dental practitioners have done far worse. After a video of Dr. Seth Lookhart, an Alaska dentist, riding a hoverboard during a dental procedure went viral, intrigued authorities found he’d been sedating nearly all his patients to cash in on the reimbursements Medicaid pays for general anesthesia. He was sentenced last year to 12 years in prison.
The Texas Dental Board revoked the license of Bethaniel Jefferson, a dentist who was practicing in Houston, after she was found to be endangering her patients by needlessly administering general anesthesia to take advantage of the same insurance payments. She left one patient in an oxygen-deprived state for so long the child suffered severe brain damage.
Dr. Scott Charmoli, a Wisconsin dentist, was charged with fraud after he was found to be using his drill to intentionally break patients’ teeth so he could bill the insurance company for crowns instead of fillings. The indictment alleges that he performed more than $2 million worth of crown procedures between Jan. 1, 2018, and Aug. 7, 2019 — amounting to more than 80 fraudulent crown procedures a month.
Weinman said patients can always seek a second opinion — especially for expensive treatments — and that a dentist who seems hesitant when you say you want a second opinion is worrisome. “A dentist who is confident in his or her abilities won’t have a problem with you checking a diagnosis or treatment plan elsewhere,” he said.
Other red flags: Weinman said to be wary of any dentist who seems to be reading from a script, or who pushes a treatment plan too hard or refuses to explain treatment options. “There may be several scientifically sound, evidence-based treatment plans available to a patient,” Weinman said, “and a good dentist is willing to explain your options — even the ones that may not be as profitable.”
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And my Republican friends wonder why in Hell I switched party registration to support Senator Sanders year before last. This is exactly the kind of crap I want to see ended. It strikes me as ludicrous oral health is not part and parcel with caring for my heart and lungs.
If anything, Tiger King Nation would have a field day if dental procedures were covered under Medicare. What we need is oversight with teeth (no pun intended) to put an end to the upcoding and ‘billing opportunity’ industries and rip the faces off fraudsters.
But it sounds like the fraud exploits the government Medicaid program.
@p fitzsimon
May 20, 2021 at 11:13 am
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So, it’s okay to defraud the federal government?
That will happen soon when we have medicare coverage for all procedures and people because people will have no obligation to check the bills!
And then there are the dental scams that are dentist-adjacent.
As mentioned here before, I used to rent a desk in a Tucson coworking space. Place went out of business in mid-2019.
During 2018, there was quite an effort to get the space fully leased. Which is why the Smile Direct Club was seen as quite the godsend. I should say that management viewed SDC that way. We, the rank-and-file coworkers, had a very different opinion.
For one thing, we quickly noticed that the whole business model was based on practicing dentistry without a license. The SDC employees were not there for patient care. Instead, they seemed to highly trained in nothing more than the delivery of scripted sales pitches for the company’s aligners. Those aligners were supposed to straighten the teeth without the need for a high-priced orthodontist.
Supposedly, these treatments were to be supervised by a dentist, but we never saw anyone who even slightly resembled a dentist.
I might add that the contract I signed noted that I was not to offer any services related to health care, services that were offered via retail sales, and services that required visits to the coworking space by retail customers. Welp, Smile Direct Club failed on all three counts.
The guy who sat across from me, who signed the same contract that I did, pointed these things out during a coworking member meeting.
Did management welcome his feedback? Hardly. They kicked him out of the coworking space.
The grift runs deep.
Now THERE’s a Bumper Snicker. Paul Harvey woulda dug it!
The Grift Runs Deep
a reaver runs through it
Here in Montanny it is
a Realtor Runs Through It
An orthodontist friend advised me to seek out an older dentist because he would not be incentivized by the massive student loan debt burdening dentists these days. And he advised solo practices for the reasons listed here.
I was referred to an oral surgeon who (I found out later) was ‘on probation’ due to mis-managing a patient who he had placed under general anesthesia to remove nine teeth, and the patient eventually died. Got a real bad vibe from him and when he had to numb me up some more he was rather careless with the novocaine. Thankfully I never had to see him again.
For 64 years now I’ve been carrying around a permanent memento of my very first attempt at riding a bicycle when I was 7 or 8 years old. It did not end well. The memento is the permanent bridge holding the false tooth where my number 8 incisor was knocked out nearly a decade earlier. The bridge consists of a gold supporting structure and a porcelain tooth glued to it. When I was in college in the late 1950s the tooth cracked when I was chewing on a pencil before a test. It was easily replaced the next time I went home and saw our family’s dentist, who had put it in.
4-5 years ago I was chewing and felt something odd and hard in my mouth; it was a large piece of the tooth. I went to see my then current dentist, who was in a group practice with at least a half dozen offices in the Minneapolis/St. Paul metro area. Based on my earlier experience I thought it would be a routine matter. However the dentist told me things aren’t done that way any more and therefore a replacement tooth for such a bridge was not available. Instead they’d replace the bridge and because I’d been their customer for ten or whatever years I’d get a 10% discount from the quoted price of $3,300. “When would you like to set the appointment?” she asked. “Family Blog that,” I thought, at least without exploring options, if any, especially considering I was carrying no dental insurance. I still remembered how much of a literal pain in the mouth it was having the bridge put in, not to mention a figurative pain in other parts of the anatomy. I could only imagine how much fun it would be to have something taken off those two anchoring teeth that had been solidly attached for half over half a century. It seemed to me that if any place nearby had access to legacy dental technology it would be the U of MN dental school, so I made an appointment for teeth cleaning and an assessment.
I was randomly assigned an appointment with an Asian-Canadian student in the third of her four year program. I told her my story and after she inspected the damage she called over her mentor and suggested she build a new tooth right onto the bridge using the current ultraviolet filling technology. He said that should work so go for it and bill him as if it were a three-surface filling. So that’s what she did in no more than half an hour. And best of all the only pain was a brief cramp or two in my jaw from holding it open. She told me to go easy on eating tough foods for the next couple of day, which I did. I’ve had no problems with it since. The total cost? $210, not counting the cleaning. Less than the amount of the “deal” they’d have given me with their discount.
Thank you for posting this. I am a surgeon with years of experience in the HMO, Private Practice and government sector as well as in the German system. The dental problem is exactly duplicated on the medical side in the US. If the government is paying by the unit smart minds will figure out how to generate more units, more tests, more surgeries. The so called “scientific literature” is polluted with “data” justifying things common sense tells us are ridiculous… When we see studies questioning some of our procedures that are popular in the US, expensive and questionable except to those who are making bank on it, we find they almost universally come from countries where surgeons are on salary and there is single payer like England and Scandinavia. The only solution to high medical and dental costs is to put all practitioners on salary, with no penalty or bonus for patient satisfaction which is simply a way of saying “giving the patient what they want….not what they need.” There should be no bonus for production. There are so many ways to milk the system and doctors are selected to be relatively smart and manipulative in the competitive process of getting through university and med school so it is an unequal battle. We need to use doctor’s brains and skills to help patients and not figure out how to suck more money out of the government. They even have courses for doctors to teach them how to best upcode and much of electronic medical records are devoted not to patient care but to better upcode so more money is billed for essentially the same work and that is how the vendors push these products. Legislators, health care economists, consumers are at their mercy. Put doctors on salary though and tell them to use what they learned in med school and residency to the patient’s best benefit as opposed to what will be the most lucrative and interesting to them and they will figure out how to get the job done with as little effort as possible and that means a vast improvement in medical care with much lower costs. And underlying that we must then eliminate the contingency lawsuit and have significant malpractice reform. Malpractice cases are a relatively low cost driver but the bureaucracy and redundancies and procedures to protect against malpractice cases slow us down, lead to worse care and are incredibly inefficient. Take just one issue….wrong sided surgery. It can happen and it is seen more often with more layers of checks and balances. If ten people are checking to see if it the right side mistakes are more likely to be made because each level thinks the other level has checked. Since we have determined healthcare is a right just like police and fire protection we need to pay doctors just like police and fire…and don’t forget…the most important care most of us will ever get is in the field or at home when the paramedics come. These salaried workers will resuscitate us and stabilize us and do it on salary, often low, and all of a sudden when we reach the swinging doors of the ER things will become fee for service. M4A is fine but the long term goal has to be eliminating fee for service and tort reform which would, of course, require M4A or something analogous.
Agree! Thanks for posting!
It’s not just dentists. My local dermatology group recently became part of Forefront Dermatology, which has hoovered up practices all over the country. https://forefrontdermatology.com/location/ Forefront itself is owned by the private equity arm of Ontario Municipal Employees Retirement System (OMERS). https://forefrontdermatology.com/omers-private-equity-acquires-forefront-dermatology/ When I went in for my annual exam recently, I was seen not by my regular dermatologist, but by a nurse practitioner. Amazingly, there were items on my bill which I had never seen before, many of which Medicare and Humana declined to cover. I am afraid that private equity is doing to dermatology what private equity has done to emergency rooms. The good news is that OMERS is at least sort of public.
Dentists are no different than your garage, the problem is us, looking for ethics in professions where profit is the motive. There aint no ethics.
I had this crowned teeth that needed a root canal.
The dentist told me that he needs to break the crown to get access to the tooth underneath to drill for the root canal and i needed a new crown afterwards.
Why cant you drill through the crown i asked him?
We could he said but the crown might break.
Well we are going to break it anyway?
He did the drilling through the crown after I insisted , finished the root canal and did the filling, 10 years later I still have the crown, it saved me $2000.
But on the other hand, why do europeans have bad teeth?
Basic dentistry is free there, and based on my experience the dentist has zero incentive to push you do any procedure if its not absolutely necessary.
The British have bad teeth (perhaps in part for hereditary reasons?). Swedes, Germans, Austrians… great teeth.
‘The British have bad teeth’
As in the Big Book of British Smiles?
https://www.youtube.com/watch?v=PrpUSKE9p_M (32 secs)
A new, younger dentist bought out my older dentist’s practice. I’ve had several sessions with the new dentist, who works faster than my old dentist, and maybe a lot less carefully, causing ulcers on the inside of my mouth in one instance which took over a week to recover from. Sad to have lost the old dentist who was more deliberate and careful, but probably less profitable. DK if I can go on with the new dentist. Strongly inclined to go elsewhere but not sure how to find a new dentist. Or maybe the motivation to move needs to increase. Well, it’s getting there.
It’s true about the sell as much as you can dentistry. We have a dentist in the family (daughter) who only worked part time over the years in private dentistry due to the huge push for cosmetic dentistry, perfection and production, even if it ruined teeth. She was fortunate to land good jobs in public health all of these years.
Post Covid, I found an angelic dentist, no flashy office, just the basics, who said I’m fine. Just a load of plaque. She did the cleaning herself! I have a totally internally destabilized tooth with an old root canal and old crown. Anyone else would have screwed around with it. No doubt, another dentist would have told me it needs a new crown etc, but the tooth would’ve fallen apart, and an extraction would be necessary. She explained this would happen. So she said we’ll watch and wait. (And implants are not an option for me.) Our “family dentist” said keep her! Conservative dentists are hard to find.
The local dental clinic here is associated with WA state community health orgs. They have a sliding scale which is great, but they constantly try to up-sell treatments. I’m pretty good at saying no.
This isn’t new or unique to the US. I experienced it in New Jersey in the year 2000, when the dentist performed many unnecessary surgeries, including replacing a perfectly good tooth with a crown, until I figured out he was running out the insurance. Actually, I didn’t figure it out, he was pushing another unnecessary crown and mentioned that I could do this before February because I still had enough money left on my annual insurance limit. I’m still peeved about it.
However, I’ve also had it happen to me in Japan, and in Singapore as well.
My solution is to find places that are not corporatized, that seem to be run as a family business, and I look at who the customers are. Honest dentists still exist but you do have to look for them.
Two years ago I had 35-year-old filling fail in a molar, finally, and needed an endodontist. My dentist, a very competent solo practitioner with an excellent staff, sent me to a younger endodontist in town because the one who had previously performed a very difficult root canal through a crown was away on Army Reserve duty. First thing this jackass did was try to sell me a $4000 dental implant, using his too-good-to-be-true top incisor implants as evidence of their superiority. I said no, without asking him if he paid retail or had the “work done” as a “professional courtesy.” My problem was multi-stage, and Dr. Quack used three temporary fillings between visits, each of which fell out. Finally I called my regular dentist for help. His assistant said that Dr. Quack would have to do the work. I replied that I would never be returning to Dr. Quack. She sighed and basically admitted I was not the first to say that very thing. Regular dentist completed the work with dispatch and all is well so far. Dr. Quack will be a one-visit wonder until he wears out his welcome. But his incisors make Bugs Bunny look snaggle-toothed. So he’s got that going for him.
Is it safe?
I highly recommend Bangkok as a place for dental tourism. No insurance required; replaced an old filling with first a temporary nylon cap and then a porcelain crown that I can’t tell apart from my real teeth today. About USD450 all-in, 2 visits, local an- and x-rays included.
This work is a commodity; there is simply no reason it ought to be luxury priced.
Last year, I had two teeth crack and realized I never signed up for my new job’s dental insurance so I was paying for it all out of pocket. The first dentist I saw told me they both needed root canals. I had to ask for the X-Rays and get an independent review from some dentists online, who agreed they didn’t actually need them. Found another dentists office, told them about the second opinion and they were able to just do cap on one and filling on the other. Ended up saving myself almost a thousands of dollars. But imagine what happens to people who don’t have the time/energy to figure this stuff out.
The fiasco sort of reinforced my views about the need for an NHS vs M4A, many American providers have adopted a certain mindset and way of doing business from the current regime and it needs to be taught out of them.
“…realized I never signed up for my new job’s dental insurance…”
It isn’t insurance. I verified it when I complained about a dental billing problem to the State Insurance Board, and they sent back a letter telling me that the Dental Plan was not an Insurance Policy.
It is a small pot of money that is doled out to you by an administer that makes it seem like insurance.