Posted and filed under Dental, Fraud, FWA.

Over the past few weeks, we have been blogging and posting about the “red-headed step-child” of healthcare fraud, dental fraud. One of our retired OIG agents recently heard this tale, which bears repeating:

At a recent visit, his mother was told by the treating dentist that she had a gum infection and needed to see a specialist (known as a periodontist) who would have to treat the infection, likely need to do a bone graft, and possibly then need a crown. The dentist making this diagnosis specifically referred her to the specialist of his preference. Instead of just taking the referral, our OIG agent’s mother, being the savvy person that she is, sought a periodontist of her choosing.

Making an appointment, and meeting with the specialist of her choosing, was an eye-opener. The periodontist made some startling relegations: there was no infection, no gum disease, no need for a bone graft, no need for a crown. What? Could it be that the referral to the specialist of the dentists’ choosing, might have been based on an interest other than that of the patient? The only thing she needed was a deep cleaning.

If there was a financial relationship between the dentist and his chosen periodontist, the problem is that there is no violation of the federal anti-kickback statute, and its likely difficult to be a chargeable offense on the local level. With no insurance implicated, it would likely be considered a “referral fee.” Of course, if the services in question were rendered, it would certainly fall into the battle of the experts as a medically unnecessary service.

Dental fraud is likely a larger problem than we commonly attribute in the healthcare fraud space. The recycling of radiographs, medically unnecessary fillings, extractions, and in the case of a recent Alaskan dentist, performing many of these services while on a hoverboard, are the tip of eyetooth. This is a very untapped space, rife with fraud.

Patients who go to dentists for services, often pay out of pocket, because many employer-based plans, as well as Medicare, do not include dental benefits. It’s unfortunately an afterthought. With many services seemingly cosmetic in nature, they are ignored. We also never hear of the unscrupulous dental provider being hit with millions of dollars in restitution, criminal charges where losses are similar to those of traditional healthcare frauds, and the like.

We at Advize have conducted dental audits and reviews for many years, in both the commercial and the Medicaid space. Contact us to see how our audits and our AI can ferret out fraud, waste, and abuse in this narrow, but important space.

Next Week: Be on the look out for another dental fraud article from guest contributor Mark R. Brengelman!