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Paying Twice for Dental Care?

Beware of unscrupulous dentists who have patients and insurers both pay for the same procedures

By Sandra Gurvis

We like to think that we can trust our medical providers, especially dentists since they are right in our mouths with various nefarious-looking instruments. But sometimes blind trust can create trouble.

A person sitting in a dentist's char. Next Avenue, illegal dental billing practices, dentist fraud
If you suspect fraud or abuse, report it to the insurer right away. Don't take "no" for an answer when contacting your insurer.   |  Credit: Getty

When I moved to Florida in June 2020, I overlooked the somewhat dodgy billing practices of my new-to-me dentist. I had just relocated from Ohio and had other things on my mind. Plus, my Medicare Advantage Plan covered $1,000 worth of dental work.

The dentist billed the insurer for X-rays, a gum ablation (a removal of gum tissue) and two fillings. While there seemed to be discrepancies between the cost of services quoted to me before they were done and what I was being billed when the services were completed, I disregarded them since my out-of-pocket expenses were minimal.

Most Patients' First Mistake

Typically — and I am hardly alone in this — I didn't bother to review the claims my dentist was sending to the insurance company. According to Bill Frazier of ESP Benefit Design in Hilliard, Ohio, this is the first mistake many patients make.

"Always review your Explanation of Benefits."

"Always review your Explanation of Benefits," he advises. This EOB, as it is known, "comes in the mail and/or is available online," if you use the insurer's website. Like a twice-daily brushing, it can be boring and tedious, especially for those who'd rather not wade through the terminology, "but it is the best way to keep track of what is being paid for and what you'll need to pay," Frazier says.

Year Two with this dentist presented a shockingly rude punch to the jaw. I broke a tooth and was told that that the root canal, post and cap would cost about $1,200, which the dentist said the insurer would not pay him directly.

So I paid upfront with a credit card, and after the work was done, filed a claim for reimbursement from my insurer. To make a very long horror story short, I learned the dentist had received $1,800 directly from my insurer — the total annual benefit amount under my policy — and claimed the total bill was $2,100. The dentist kept about $350 of the $1,200 I paid on the day service was rendered.

Lessons Learned Along the Way

Six months later, I am still sorting it out. Here's what I've learned so far:

Ask for and keep an estimate and written statement. "Most dentists will provide this to you upfront, without asking," notes Frazier. While not particularly vigilant with this particular provider about getting a printed-out estimate, I did have a record and receipt of the amount I paid upon completion of services.

Pay with a credit card. "Credit card companies are very, very strict, especially when it comes to medical services," says the billing manager of the dental practice I currently use. When I called Care Credit, the company that issued the medical credit card I used to pay the dentist, not only did a representative email me a follow-up letter the next day but the company also froze the amount in question, so I wouldn't have to pay on that amount or any subsequent interest. Less than a month after I filed, they refunded the amount to my account.

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When contacting the insurer, don't take "no" for an answer. "If you suspect fraud or abuse, report it to the insurer right away," advises Chuck Czajka of Macro Money Concepts in Stuart, Florida. This may require persistence and patience: I am now on my third complaint analyst, as the first one seemed inexperienced and wanted to close the case due to the dental office's gaslighting (another long story) and the second never bothered to request my receipts which proved the discrepant amount. But if you have a legitimate beef, eventually you'll find someone who's willing to take ownership.

"State agencies take potential fraud and abuse situations very seriously."

File a complaint with your state's insurance watchdog agency. If you can't resolve the issue with your insurer, you have several other options. "State agencies take potential fraud and abuse situations very seriously," emphasizes Frazier. In fact, most states have an entire department dedicated to handling fraud and other insurance issues.

The Ohio Department of Insurance offers a consumer complaint form, while in Florida, fraud and scams can be reported via the Florida Division of Consumer Services insurance consumer helpline (1-877-693-5236). If you are unable to locate such an agency, start with your state's Attorney General.

Contact other resources as well. Government agencies such as the Department of Health and Human Services, the HHS Office of Inspector General, the Centers for Medicare and Medicaid Services and the Health Care Fraud Prevention Partnership, "share information about fraud detection," which can help expedite and resolve issues, says Czajka.

Along with casting a wider net in catching repeat abusers, these agencies can also offer specific avenues of recourse. Public-private partnerships such as the National Healthcare Anti-Fraud Association (NHCAA), also provide resources and information.

Dental Fraud May Be a Billion-Dollar Problem

"Occasionally health care workers, doctors and even patients commit Medicare fraud without knowing it," says Czajka. While I was fine with the work and demeanor of the dentists and their support staff and followed basic guidelines in selecting the practice, when I tried to resolve the billing situation by calling my insurer on my cell, the office staff ordered me to leave the office.

At that point, I realized this was more than a simple oversight, at least administratively. "Overpayments should be promptly returned and health care providers impeccable in their business and billing practices," adds Czajka.

"If someone's thinking about committing fraud, they'll figure it might be easier if that person is older."

Such practices not only hurt consumers but also run up costs for providers and insurers. A conservative estimate for financial losses due to all types of health care fraud is about 3% of total expenditures, states the NHCAA, which adds that "some government and law enforcement agencies place the loss as high as 10% of our annual health outlay."

Research and Markets estimates that the U.S. dental services market will total about $50 billion this year and grow to $72 billion by 2027. Three percent of this year's revenue is about $1.5 billion, which may reach over $2 billion in five years.

Although this makes my situation look like a tiny cavity in an entire set of implants, as Frazier points out, "if someone's thinking about committing fraud, they'll figure it might be easier if that person is older." But like Frazier's 91-year-old mother-in-law, who he says "goes over every EOB with a fine-tooth comb," I am now out to prove them wrong.

Sandra Gurvis Sandra Gurvis is the author of 16 books and hundreds of magazine articles. A freelance writer for more than 25 years, she has also written corporate profiles and technical articles for clients such as Ohio State University Wexner Medical Center, Ohio Health  and Merrill Lynch. She is also the author of Where Have All the Flower Children Gone? (University Press of Mississippi).   Read More
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