"Dr. Michael W. Davis maintains a private dental practice in Santa Fe, NM. One day per week, he assists at a dental clinic focused on disadvantaged children and adults. Dr. Davis chairs the Santa Fe District Dental Society Peer-Review Committee. He is also an active member, in the New Mexico Dental Association House of Delegates, which drafts legislation relating to public protections in dentistry. Dr. Davis also serves as an expert witness, in dental legal cases. He may be reached at: MWDavisDDS@comcast.net
Mechanisms of Dental Sealant Scams
By: Michael W. Davis, DDS
September 16, 2014
Dental sealant scams have been a mainstay hustle, in unethical dental practices for numbers of years. The insurance industry terms this dishonest and unlawful activity, “upcoding”. It’s a highly lucrative and successful play, especially in Medicaid settings, because it costs nothing from the patient, and there’s no pain or discomfort generated. Here’s how it works.
The crooked doctor etches the tooth’s enamel surface with an acid gel, which has no dental caries (dental cavity). The tooth may or may not have a stain, which certainly doesn’t require clinical restoration (filling). Next, they place a flowable resin-composite into the tooth’s pits & grooves. This is a tooth-colored material, which lacks physical properties of strength and wear resistance. Manufactures never recommend flowable resin-composites to be used in high physical stress areas, like the chewing surfaces of teeth. Basically, the clinician has delivered the service of a dental sealant.
However, unlike a preventive service like a sealant, this “service” is billed out as a resin-composite restoration. Not only does this activity generate more billable fees, but also each surface the flowable resin-composite contacts generates additional billable fees. While a preventive dental sealant may command in the neighborhood of a $35-40 fee, a multiple surface resin-composite restoration will produce a fee ranging from $85-170. The only real limitation is the greed of the dishonest dentist.
Sometimes, the doctor may actually roughen the enamel surface, for better adhesion of the restoration (in reality, a sealant). However, because of the compromised material used, a general lack of adjusting of the patient’s occlusion (the manner in which teeth bite together), and the rush to maximize production under a challenging Medicaid fee schedule, this form of restoration has a compromised longevity. The compromised longevity is yet another moneymaker, in that these “fillings” require frequent replacement.
When I’ve audited Medicaid patient records, it’s rare to actually see any radiographic evidence of tooth decay on teeth restored like this. (On review of x-rays, there’s no indication of any prior tooth decay.) Further, once these teeth are restored, there’s still no evidence of these restorations entering dentin (Dentin is the tooth structure under enamel, which is a qualifier for a definitive dental restoration, under most Medicaid and insurance programs).
One exception is “preventive resin restorations” (PRRs), which are not a covered service under most insurance and Medicaid plans. Under magnification, and using micro-air abrasion or a fissurotomy bur, the doctor selectively removes only the caries-affected enamel. PRRs do not command an equal fee for restorations, which enter into dentin. However, that won’t stop an unethical dentist for charging, for the more lucrative service.
A sealant scam is difficult to pull off, with private pay and dental insurance patients. Here are the reasons why.
Whether the patient (or their parents) pays the full amount, or simply a lesser-required co-payment, they have “skin in the game”. They feel a pinch in their pocketbook. If these “fillings” fail to hold up, which is virtually guaranteed, patients will complain. They may complain to the doctor, the state dental board, professional peer-review, a civil attorney, their insurance company, or their employer who purchases the dental plan. They are also highly likely to discontinue services with an unethical doctor, who provides this disservice.
By contrast, Medicaid patients have no skin-in-the-game. They pay nothing. They absolutely rejoice, when a dentist places a large “filling”, which doesn’t require Novocain (local anesthetic), and never hurts. They have no concern; this “restoration” is replaced or repaired every 2-3 years. This creates an ever-renewing financial annuity, for a crooked doctor.
Further aiding the dishonest doctor is the abysmal to nonexistent oversight provided by Medicaid regulators. While dental insurance auditors are very well aware of this common dental scam, Medicaid auditors are generally clueless. I seriously don’t know if Medicaid auditors are mostly corrupt, lazy, or stupid. Regardless, I don’t have the time or energy, to broker fools.
So far, I’ve focused on the role played by dishonest dentists. Numbers of corporate dental clinics also play this fraudulent game on Medicaid. These dental service organizations (DSOs), which purport to limit their supervision to non-dental activities, misrepresent the reality. They are active in instructing doctors, on how to cheat the system. The private equity investors, clinic managers, and fraudster doctors all dip their collective beaks, in taxpayer largesse. This represents corporate fraud on a massive interstate level. Unfortunately, since the victims are disadvantaged Medicaid beneficiaries and US taxpayers, regulators generally sit on their hands, or hide under their desks.
In conclusion, misrepresentation of dental sealants as resin-composite fillings is not a “billing error”, as some dental crooks would have you believe. These “fillings” are often placed upon specific teeth, and surfaces of teeth, not covered under a Medicaid program for sealants. These are intentional misrepresentations to deceive the Medicaid program, for one’s financial gain at taxpayer expense. This represents violations to the Unfair Trade Acts and False Claims Acts (both state and federal), which is fraud. Fraud is not malpractice, and a doctor’s malpractice insurance generally doesn’t cover for acts of fraud. Acts of fraud often carry both civil and criminal penalties. Financial penalties are generally treble (3X) damages.
We already have state and federal legislatures, which have enacted powerful laws onto the books. The problems primarily lie with worthless regulators. They are unwilling to enforce existing laws, to protect the disadvantaged and taxpayers. Government regulators too often serve as enablers, for white-collar criminal activity.
From my perspective, I hold Medicaid auditors and regulators to equal culpability, as the actual violators. By ignoring their lawful responsibility to enforce the rule of law, regulators give criminals a tacit green light. Sadly, this green light perpetuating dental Medicaid fraud has been frozen on “go”, for many years.
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