Posted and filed under Dental, Fraud, FWA, Medical Record Auditing.

Our Founder and Managing Director Jeanmarie Loria sat down with retired OIG Special Agent Eric Rubenstein to discuss dental fraud, unscrupulous dentists, and the claims-related intricacies of the dental industry. Here’s how it went…

JL: My aunt in California paid an additional $10 for personal protective equipment (PPE) on top of her dental visit. Other members of my family in NY paid $15 for PPE, yet your dentist in NJ charged nothing extra for PPE. What gloves…I mean what gives? Why are some dental offices charging extra for PPE, and how is there no standardization when it comes to this practice? 

ER: I am not sure what the costs for dental in particular are, but general PPE are gloves, masks, and likely, a face shield – at minimum. If you break that down with a quick internet search you’ll find that:

  • Amazon charges $35 for a 10 pack of N95 masks ($3.50 per mask)
  • Walmart charges $24 for 50 non-N95 masks ($0.48 per mask)
  • Amazon charges $18 for 100 non-latex gloves ($0.18 per pair)
  • Amazon charges $26 for 10 face shields ($2.60 per shield) 

This averages out to $6.76 total cost using the N95 masks. My dentist (whom I saw 3 weeks ago for a cleaning), used the same PPE before the pandemic. The only additional item was an air filter of some sort to capture airborne particulates. I did not pay anything additional as a fee or other non-covered costs for PPE. I think it is just a money grab by providers wanting to add a non-reimbursable fee like that. The PPE is used for universal precautions all the time, so it’s just a bad public relations thing. 

JL: As an agent with 25 years of fraud investigations under your belt, what do you know about dental fraud? 

ER: Dental codes and schemes are very similar to traditional healthcare fraud in that services not rendered, upcoding misrepresentation of services, and drug diversion are incredibly common. 

JL: You spent your career looking at DME, pharma, and not dental. Right?

ER: I spent my career looking at all healthcare. The reason I didn’t look at much dental is because it is not a Medicare-covered service and it is mostly Medicaid. Medicaid fraud is handled by the Medicaid Fraud Control Units (MFCU)

JL: Why don’t you think Medicare covers dental?

ER: Because when Medicare was created, it was created to treat illness or injury, and dental wasn’t included in that grouping. So, while Medicare has evolved to cover preventative services as well, it has continued to exclude dental as a benefit. 

JL: That means many retirees are spending lots of money on the out of pocket costs…

ER:  Or they need to obtain a secondary plan that has a dental benefit. 

JL: Dental health is so important beyond appearance and confidence. I saw my aunts and uncles struggle all their lives from dental fraud that victimized them as kids. A lot of studies suggest that cardiovascular disease is linked to dental health, showing that the connection between poor oral health and overall health may not be limited to heart disease. Do you think dental is rife with fraud because nobody is looking at it?

ER: It’s hard to make that assertion but there is more money spent on healthcare than dental, and focus is almost always where the money is. 

ER: There was a dentist in the NYC area who had another unlicensed dentist working for him. The unlicensed individual was from a South American country and was purportedly a dentist in his home country. He was not licensed in the US but was providing dental services to patients at the dental office. The claims were all being submitted under the licensed dentist. During an arrest for the unlicensed provider, we found an entire dental set up in a back bedroom; he was performing dental services in his house for people in his community. He had instruments, a dental chair and appeared to be able to do things like fillings and extractions. It was a bit of a shocker to see all of that. Big dental cases like that are something that we would sometimes see, but I can’t think of any of my colleagues who focused solely on dental fraud.

I thought that old dentist’s chair would make patients need a tetanus shot.

Eric Rubenstein

JL: One thing I’m interested in exploring is dental fraud in adults versus children. I imagine it’s easy for predatory dentists to use children. Their teeth fall out, and evidence can easily be lost. 

JL: Why are we as patients asked to be dentists? Typically, we aren’t asked to give an opinion of what we want for treatment when we go to the ER.

ER: There’s a lot to consider when it comes to dentistry. There’s cosmetic versus restorative, and the activities of daily living that all come into play. 

JL: If my dentist is trying to upsell me or services or procedures, what should I do? Example, one dentist says I need a root canal, I waited on it and another dentist says that there’s no need for it now.  How do I know it is wrong without getting a second opinion?  What if my dentist tells me to buy the tooth whitening tray, but I know from my dental friends that crest white strips are better and so much less costly?

ER: Dental and vision always seem to be after thoughts with insurance.  Sometimes it is part of plan’s offerings, and sometimes members need to actively seek it out.  For those who do not have insurance, and pay out of pocket, there is always a menu of options when it comes to these specialties.  Pill the tooth, fill the cavity, get an implant, get a crown.  There are always lists of what everything costs, and unlike traditional healthcare, people will go for an extraction and not do anything beyond, but if a person is offered a particular test or treatment, people will often question much less. 

JL: If there was a wider offering and use of dental and vision, is it a plausible discussion that potential instances of fraud would be lower, since insurance has some stop gaps to prevent and investigate FWA, or worse because the vault is then open? 

ER: If a patient gets defrauded on a cash payment, who do they report it to?  Regulatory agencies are only interested in licensure related matters, so you would likely need to report it to some law enforcement agency as a theft type matter.  What are the chances that the local police department will investigate a $300 dental fraud case where the patient was talked into, or not, getting a filling they didn’t need? Slim.

This week’s blog on dental fraud is the second installment of a mini-series we’re doing on less-known forms of healthcare fraud. Tune in next week for another dental health article of the series!