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Medical Forum / General / Dentistry / June 2005

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Parents victims of dental fraud?  What can be done?

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spamnadazilch@yahoo.com - 04 Jun 2005 09:24 GMT
I'm becoming increasingly concerned that my parents are victims of
dental fraud and I would appreciate professional opinions on possible
recourse or what they should do at this point.

Among the many, many fishy things to go on (with their DMO dentist) are
the following:

Price is quoted for say $800.  Once the procedure is underway, it's
$1600 ("oh, didn't we tell you that was per tooth!?").  To make
matters worse, this procedure (among many others they have done) could
have been substituted with a covered/free procedure but they weren't
properly presented with these options.  I fear, however, that they've
probably signed paperwork that will hide the office's deception.
"I have been presented with alternatives, etc. sign here."

My father has appeared 7 times for scheduled teeth cleanings and keeps
getting inane excuses as to why they can't take him that day and that
he'll have to come back.  Unbelievable!

They extracted my dad's tooth and left part of the root in.  When
going in to fix it they broke a crown.  When my father's there to get
it fixed they hand him the bill to fix the crown.  Shouldn't they be
paying for their own mistakes?

They did one-half a deep cleaning on my dad and when he went to finish
the other half he clarified with the dentist that it was already paid
for.  Once assured of this he agreed and surprise, surprise he got a
bill for the second half after he's in the chair ready to go so, of
course, he signs and pays.

The problem I see is that throughout all of this they have paid before
even leaving the dentist's office.    How can they possibly have any
recourse if they continue to pay?!  I plead with them to switch
dentists but since my dad is in the middle of a procedure they're
sticking with this one.  With this last visit my dad finally asked for
his medical records and was refused.  I'm finally left thinking I'd
better try to do something on their behalf since this can't go on.
(They've actually had to take out a loan for what has amounted to
over $5000 in dental bills).  They feel confident that by complaining
they'll get their money back but so much of this isn't documented
but just "they said/I said", so do they really have a shot?  Also,
does it water down their case when they keep going to this dentist?
Their "plan" has a fraud department but will that help get their
money refunded once it's already been paid?  I have begged them to
not get anything done without getting it in writing but my dad assures
me he knows what he's doing and he'll take them to small claims
court.  I just have that sinking feeling they won't have a leg to
stand on after the fact (and retirement is looking farther and farther
away with each procedure - my parents' not the dentist's!).

Please help!!!  What can I/they do?  They don't want to make the
dentist angry since they have to keep seeing her right now but I say
they need to start talking lawsuit or complaints to professional
associations.  By the way this is in California.

Thanks for any help.  I'm feeling pretty desperate right now for help
from someone who knows what's what.
Steven Bornfeld - 04 Jun 2005 13:27 GMT
> I'm becoming increasingly concerned that my parents are victims of
> dental fraud and I would appreciate professional opinions on possible
[quoted text clipped - 53 lines]
> Thanks for any help.  I'm feeling pretty desperate right now for help
> from someone who knows what's what.

    What you have described is the stereotype of the DMO (capitation)
model--that the dentist is paid by the subscriber and not the treatment,
so there is a disincentive to get patients into the office to do work.
Once they are there, there is a tendency to steer patients to the few
procedures that are not covered under the plan.
    Most of the insurance companies that run these plans are not dumb, and
must know that this goes on.  My conclusion is that they are not trying
very hard to eliminate these practices.  If they didn't tolerate these
practices, many dentists would drop off their panels, and the insurance
companies wouldn't be able to show purchasers of the insurance that
nice, long list of participating providers.
    I don't know what the law is in California, but in NY a patient MUST be
furnished with a copy of their records if requested (a "reasonable" fee
is permitted for duplication).
    My feeling is this would be difficult to prove this rises to the level
of fraud, as your father by continuing to be treated could be seen as
giving tacit approval to the office's policies.  If however there was a
signed agreed upon treatment plan that you can demonstrate was deviated
from you may be able to do something.
    The thing which may be the most troublesome thing in your description
is the repeated refusal to treat for scheduled appointments.  This could
be seen as abandonment, or perhaps insurance fraud.  I wouldn't go to
the insurance company though.  I would inquire at the state board for
dentistry or even the state insurance department.

Good luck,
Steve

Signature

Cut the nonsense to reply

Steven Fawks - 04 Jun 2005 14:21 GMT
> Among the many, many fishy things to go on (with their DMO dentist) are
> the following:

If the DMO isn't saving money (they rarely really do in dentistry), then
dump the stupid plan and find a dentist that you trust.

People get trapped in the "insurance mindset" and think they cannot
afford dental treatment without it (or somehow think treatment should be
free).

There are many good dentists who refuse to participate in DMO scams and
would be happy to help.

Fawks
leaderdmd@juno.com - 05 Jun 2005 18:16 GMT
I am the State Peer Review Chair for the Massachusetts Dental Society.
This is exactly the type of problem that we handle.  Here is the web
address for the Peer Review committee for the California dental
Association:  http://www.cda.org/public/policy/peerrev.html

Peer review is only appropriate if the dentist is a member of the
dental association.  If not, you will be directed to the appropriate
state agency.

David Leader, DMD
Malden, Ma.
spamnadazilch@yahoo.com - 06 Jun 2005 22:52 GMT
Thanks for that information.  Very helpful.  By any chance do people
ever end up getting their money back via this process?
Dr Steve - 06 Jun 2005 23:02 GMT
If they paid for services they did not receive money is returned.

Signature

~+--~+--~+--~+--~+--
Stephen [What's a Temporary?], D.D.S.
Michigan, USA
....................................................

This posting is intended for informational or conversational purposes only.
Always seek the opinion of a licensed dental professional before acting on
the advice or opinion expressed here.  Only a dentist who has examined you
in person can diagnose your problems and make decisions which will affect
your health.
......................

> Thanks for that information.  Very helpful.  By any chance do people
> ever end up getting their money back via this process?
spamnadazilch@yahoo.com - 06 Jun 2005 23:18 GMT
The problem is that they've been duped into procedures that were
performed but they didn't explain that there were options that would
have been covered.  There's also that thing where they cracked his
crown yet they made him pay to fix it.  Does any of that qualify for
reimbursement due to fraud?
Dr Steve - 06 Jun 2005 23:30 GMT
Can you prove the crown was not flawed before treatment?  Generally, a crown
which breaks like that, was flawed and would have broken soon anyway, but I
wasn't there, so who knows?  That is the problem.  Believe me, I am the last
person to defend a DMO dentist as I think they play a wicked game of
bait-and-switch.  However, if the treatment was needed and was performed
well, you cannot readily argue, after the fact, that you would have wanted a
different treatment choice.  You can, however, argue that it is misleading
to be presented with a plan which covers certain specific procedures at 100%
coverage, but the offices which are listed as participating offices do not
perform any of the covered procedures and make every effort to prevent you
from receiving any of the covered procedure which they still perform.  I
don't think this qualifies as fraud unless you want to argue that the
employer represented the plan as 100% coverage, but then the providers
refused to provide covered services.  Even then, I am not certain if that is
fraud or just being un-ethical.

Personally, I think it should be discussed first with the employer who buys
and pays for the plan.  Then, it should be discussed with the carrier.
Especially it should be discussed with co-workers who might be fooled into
signing up with the same scheme.

Signature

~+--~+--~+--~+--~+--
Stephen [What's a Temporary?], D.D.S.
Michigan, USA
....................................................

This posting is intended for informational or conversational purposes only.
Always seek the opinion of a licensed dental professional before acting on
the advice or opinion expressed here.  Only a dentist who has examined you
in person can diagnose your problems and make decisions which will affect
your health.
......................

> The problem is that they've been duped into procedures that were
> performed but they didn't explain that there were options that would
> have been covered.  There's also that thing where they cracked his
> crown yet they made him pay to fix it.  Does any of that qualify for
> reimbursement due to fraud?
cherryo - 06 Jun 2005 23:39 GMT
Thanks so much!  I really appreciate your taking the time to help me
out.  God bless.  :)
Dr. Steve - 05 Jun 2005 20:57 GMT
>I'm becoming increasingly concerned that my parents are victims of
>dental fraud and I would appreciate professional opinions on possible
[quoted text clipped - 53 lines]
>Thanks for any help.  I'm feeling pretty desperate right now for help
>from someone who knows what's what.

DMO = Bait-and-switch.  Please tell everyone you know how this works,
too  many people fall for this trap. there is no free lunch. No dental
office can afford to stay in business doing the free work covered by a
D MO. They have to bait the patient into expensive treatment that is
not covered to remain in business.
..
Stephen Mancuso, D.D.S.
Troy, Michigan, USA

I am writing on a Tablet-PC,so forgive me if the PC misreads my handwriting.
 
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