Scams played on dentists: Part 3 -- The insurance industry

In the final part of this series, Michael W. Davis, DDS, details some of the ways dentists and dental offices are vulnerable to scams. This part discusses the insurance industry and concludes the series.

Insurance industry

Most dental practice owners are only too aware of scams played by the insurance industry. "We never received a copy of patient x-rays for review. So, we can't make payment at this time." Yet the initial insurance preauthorization approved the treatment based on x-ray copies, which were submitted. The radiograph clearly demonstrates extensive dental caries undermining a cusp and need of crown coverage. Yet, the claim is not allowed (probably based on the clinical observation of a nondentist, still working to obtain a GED).

The U.S. insurance industry's primary obligation is to its shareholders and to make them a profit. The best interests of patients often don't make it onto their radar screen. With delay and denial of claims, they hold additional moneys in accounts of outside investments. Additional profits are generated.

Michael W. Davis, DDS.

For a limited few dental practices, they can opt out of the insurance game. Unfortunately, the majority of dental practices must deal with insurance and their deceptions and misrepresentations. Without some insurance coverage, many patients would receive only very limited or no dental care.

Dental practice owners must crunch the numbers given the fee schedule amount, how much an insurance plan pays for a given service, or collection of services. The practice owner has to ask if the practice can, one, maintain profitability and, two, deliver a reasonable standard of care to the patient?

Believe me, corners are cut in most dental demographics, which violate standard of care and state statutes, to generate a profit under the most miserly preferred provider organization (PPO) plans. Is one willing to utilize offshore dental labs of questionable quality to maintain profitability? Is one willing to use "gray market" or black market dental supplies to lower overhead expenses? Is one willing to utilize unlicensed and uncertified auxiliaries to make the numbers work?

Are you willing to take those liability risks? Others definitely are doing so and generating healthy profits. A limited few practice owners face actions in civil and/or criminal court, as well as administrative law hearings. Some hire nominee dentist owners to shield them from possible liability consequences. From my perspective, much of these unethical shenanigans go back to the insurance industry and the unhealthy systems they were allowed to establish and maintain.

Conclusion

A recent graduate may read this article and conclude that ownership and operation of a dental practice are simply too difficult. There are far too many pitfalls. One would just like to go to work, focus on the dentistry, and collect a paycheck. Some older dentists would like to leave their private practice and just go to work for some group.

That's exactly the bogus talking points line that many clinic owners are depending you will bite on. They want you to fear ownership of a private solo or group practice. They want you to fear the insurance industry, the consulting scam artists, the practice brokerage hustlers, and possible employees who may cheat you. They want you mired in fear, so they can retain you, often pretty much like an indentured servant. Don't take the bait. The myth of the greener grass is just that -- a myth.

I can't begin to tell you about the doctors older than age 45 who sold their dental practices because of all the daily frustrations. Then began a new frustration of going from employer to employer, attempting to find an ethical and responsible dental office to work for. In the end, many just returned to where they started and re-entered ownership of private practice.

There is no doubt that for some doctors it makes no sense to retain ownership in part, or in whole, of a dental practice. However, simply to get admitted into dental school means an individual is very special. The unique set of skills learned in any dental program sets one apart from the majority of society. Dentists are not average people by any measurable standard.

Today, especially, doctors are not isolated. We receive collegial support and information via the Internet, on venues such as this one, DrBicuspid.com, and a long list of others. Organized dentistry (American Dental Association and Academy of General Dentistry) has established new dentist committees at both the state and national levels. Most district dental societies have volunteer dentists who serve on peer-review committees. Most of these resource colleagues know "where the bones are buried." They'll talk to colleagues and offer pointed advice on career options, and "bad apple" practices and employers. The hustlers and scam artists in the dental industry are no longer cloaked by professional silence. The word is getting out.

I recommend you act with a strong background of information and knowledge. Arm yourself with the assistance of colleagues and other valued professionals. Reacting out of fear can lead to rash decisions with potentially very negative consequences. An attitude of "I just want to keep my head down and do the dentistry" often leads to problems. Doctor, keep your head up and on a swivel. Be alert. Be aware. Be alive.

Michael W. Davis, DDS, maintains a private general dental practice in Santa Fe, NM. He serves as chairperson for the Santa Fe District Dental Society Peer Review. He is also active in expert witness legal services.

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.