Billing patients ethically

Imagine going to the dentist’s office (1) You have just arrived for your dental recall appointment and now the dentist’s receptionist  recognizes that according to your dental insurance, you’re one week early so your dental ‘insurance’ plan won’t pay, it’s not been exactly six months since your last recall appointment.

Dental claims

Can you ask to just change the date on the claim form to “next week” so that the claim form can be submitted and can be covered and not waste your entire afternoon? What if instead of one week early, the appointment is only one day early. Does it make a difference to what the dentist can do? 

Imagine going to the dentist’s office (2) when your dentist routinely recommends to you and all the longstanding “regular” patients that you should have complete examinations and a complete set of x-rays every three years, it’s what the office does.

Most dental plans cover such services and you see nothing wrong with your proposed treatment. Is this ethical though? 

Imagine going to the dentist’s office (3). In your dentist’s preventive oriented dental practice, talking to the receptionist you learn that virtually every adult patient receives the same 45 minutes of cleaning, scaling and topical fluoride treatment at their recall appointments. Is this ethical? 

Imagine going to the dentist’s office (4) when your dentist has just taken a dental course and learned that periodontal (gum) surgical “curettage” or scraping should be performed routinely on such patient’s gums. (Not only will they be helping their patients, but they will be able to generate considerable income as it is “typically” a covered benefit under dental insurance plans.)

However, a periodontist (gum specialist) later tells you that the efficacy and “need” for periodontal surgical curettage is highly questionable. It didn’t cost you anything, but has your dentist been billing ethically for this service? 

Dentistry – short appointment, high cost (5).

Your dentist prides themselves on taking numerous continuing education courses and utilizing the latest technology in the delivery of dental care to you and their patients.

Your dentist prides themselves on taking numerous continuing education courses and utilizing the latest technology

As a result, with the use of conscious and deep sedation / general anaesthetic techniques, they are able to provide extensive care quickly – and charge thousands of dollars for dental treatment rendered at one dental visit which far exceeds what they would be able to charge you if they provided the same treatment over multiple visits in a “conventional” appointment regimen. Is this ethical billing? 

Ethical dental issues

Other than the first hypothetical scenario offered above, the remaining scenarios touch on the underlying ethical issues related to the billing of patients in an everyday dental practice. Scenario One is actually not an ethical dilemma at all.

It is simply a straightforward example of a dentist being asked to commit fraud, a professional misconduct – and the dentist should of course not complete or submit any claim form even at the patient’s request.

However, Scenario One does have one thing in common with the other scenarios, namely that it is intimately tied to the submission of claims to third parties using procedure codes defined and set out in dental fee guides which dentists commonly use in dental practice. 

All too often patients don’t really know, or care what is being billed.

“I don’t care, providing I don’t get charged anything,” is alas a dangerous approach. As a patient you (if you’ve signed a consent to say so) are responsible for all fees, regardless of whether they’re “covered” by your dental coverage or not.

Dental insurance is in fact not insurance but “pre-paid dentistry” most of us carry life insurance, car insurance, home insurance, etc. and those are quite different. It seems probable that by maximizing payments from your insurance company, changes may occur that will affect payment to you and/or others with that same coverage in the future.

With respect to the other scenarios, the underlying concerns are related to the appropriateness of the type, quantity and frequency of the procedure being performed and amount of the fee charged for the service provided. 

The issue rests squarely on not what the dentist is legally permitted to do, so much as what the dentist perceives to be the “right thing to do” when recommending specific treatment and setting a fee for services rendered to his or her patient. 

Dental fee guide

Although there are a number of factors which influence the choice of treatment a dentist may recommend for his or her patients, one of the chief determinants which affect the ethical choices being made by dentists regarding treatment and fees being charged is the dental fee guide itself.

In my view, even well-meaning dentists can misinterpret and misuse the procedure codes and suggested fees listed in fee guides without realizing what they have done. This can result in both ethical dilemmas and legal liability for the dentist.

The problem may be magnified when the patient has a dental benefits plan and the dentist is aware of what procedure codes in the fee guide are a covered and those non-covered benefits which in turn may affect the dentist’s objectivity in recommending and performing certain dental treatment for the patient. 

The problem may be magnified when the patient has a dental benefits plan and the dentist is aware of what procedure codes in the fee guide are a covered

What dental treatment did you sign up for?

Remember you are responsible for the fees if you’ve signed a consent. What did you sign and what was it for. Was it “everything for ever?”

What is a dental fee guide? 

Most practising dentists are familiar with suggested fee guides. These are made available to dentists and list a number of specific procedure codes representing countless dental treatments and services which may be performed by a dentist for a patient. 

In a typical dental fee guide, the codes typically describe specific dental procedures and related fees which a dentist could charge his or her patients for a range of dental procedures.

Putting a procedure code in a fee guide does not mean that the procedure itself should be rendered and/or that the suggested fee should be charged when the procedure is performed.

Ethical billing issues arise when the dentist elects to perform certain procedures and charge certain fees because the codes and fees primarily enhance the profitability of the dentist’s practice rather than because the procedures and fees are in the patient’s best interests.

There is no question that a dentist must have a profitable dental practice, otherwise the business will not remain; however the ethical issue is how much profit is reasonable on a fee for service basis and/or on a per patient basis in the context of a privileged, limited access, health regulated profession? 

How much are you worth to a dentist?

Considering the financial ‘worth’ of an individual patient has always been an abomination to me yet is not uncommonly considered as part of a business plan.

Legal problems related to billing can include, but are not limited to, using the wrong procedure code for the treatment performed, not providing the treatment which has been claimed or charged for, providing an unnecessary service and charging a fee which is excessive in relation to the service performed.

Informed consent in dentistry

Informed consent in dentistry is a very important and frequently misunderstood topic in dental practice.

Failure to obtain informed consent to treatment including the costs of the proposed treatment can also constitute professional misconduct– consent is a process and covers informing you what (exactly) is going to be done and your other options and costs. Also, that you agree to this and the fee you will pay.

Ethical problems related to billing can involve using a procedure code which may not fully describe what service was provided, using a code in a “grey area” of the fee guide code, rendering services and charging fees which are more intended to generate undue profit for the dentist rather than being reasonable and fair in the best interests of the individual patient, be aware, the patient is not exempt of responsibility from the claim of and association to defraud.

Dentists and fraud.

I knew a dentist who having defrauded the carrier for some time was caught. He blamed his staff for the mistakes and unable to prove otherwise, was excused.

Another dentist with whom I worked for a short time did the same but blamed his wife, who did the ‘reception and bookkeeping’! In this case even though the evidence was somewhat strong, the judge decided to overlook the transgression on that occasion too.

Hopefully, these examples are not typical, however.

Dental fee schedules or guides

A fee guide is precisely that, a ‘guide’ to help the dentist set the fees the dentist wishes to charge for treatment rendered in the dentist’s own dental practice, where allowed by law.

A fee guide is not mandatory and where actual dental fees have not been set by legislation, no dentist is obligated to charge the fees recommended in a fee guide.

Therefore, there is a degree of freedom among dentists to individually determine what fee they feel they should charge for their dental services. However, once the dentist sets his or her own dental fees, then this becomes the dentist’s ‘fee schedule’.

The patient can then be told what the dentist’s fee will be for a given procedure. 

The patient can then be told what the dentist’s fee will be for a given procedure. 

In principle, this means that a suggested fee in a fee guide cannot be applicable to every dentist since every dentist does not have the same equipment, instruments, furniture, lease expenses for their office premises, leasehold costs, cost of supplies, leased equipment costs, office overhead expenses, staff expenses, qualifications, skills, knowledge and experience as the next dentist.

As such, it is possible that every practising dentist and/or dental practice should have its own fee schedule which differs from that of other dentists depending on the particulars of the dentist’s dental practice.

For instance, should a new graduate charge the same professional fee for restorations as an experienced dentist? Is the patient receiving the same value within the same practice from a recent graduate vs. the senior dentist?

Typically, fee guides do not clearly stipulate the various factors which should be taken into consideration when a dentist determines a specific fee schedule for the dentist’s own dental practice, there are therefore limitations.

While it is not absolutely necessary, posting fees for the benefit of the patients could be seen as a step toward transparency, but willingness to discuss fees is adequate. 

Where a dentist does work out their costs and therefore fees, for his or her own patients, determined after a thoughtful and deliberate analysis of the particulars of the dentist’s practice circumstances, expenses and reasonable profitability objectives, the likelihood of the dentist being able to bill his or her patients ethically, is enhanced. 

If the dentist simply incorporates the fee guide as the dentist’s fee schedule for his or her practice without actually performing the aforementioned analysis and perhaps not even reading the expressed principles of the fee guide being relied on, the likelihood of improper and unethical billing is increased. 

The answers to ‘going to the dentist’s office’

(1): Neither the patient or the dentist can misrepresent the facts by submitting incorrect information on the claim form to suit. The criminal, statutory (professional) and civil legal consequences can be dire for both. This is fraud. Incidentally not charging the co-payment or balance from that paid by an insurance carrier is also fraud. 

For instance, if you indicate that you have a concern which requires a specific examination then it would be reasonable to perform such an examination and submit a claim for it with a fee for the service rendered.

However, if in fact you are being seen as a recall patient and the patient’s “additional” concern is assessed as part of the recall examination, then submitting a specific examination code instead of the recall examination code and charging a higher fee for same in such a circumstance may well be unethical and illegal too. 

(2) :If you see your dentist for regular recalls, recommending a complete examination and a full set of x-rays automatically every period of time may be considered unethical as well as illegal (i.e. unnecessary dentistry). It depends on what and why the dentist is suggesting it. There is nothing wrong with ‘guides’ but it is the dentist’s responsibility to seek what is best for your individual needs.

Any treatment should only be performed only when necessary and there are indications to justify doing so. We are entering a time of expediency. In working for others, I have often been asked to see a patient for the first time after they’ve had their tests (x-rays). Taking x-rays for example, cannot be delegated and the prescription of tests (x-rays) must be given by the attending dentist, so the dentist has to see you first to decide what tests and/or x-rays you need, if any.

Equally, from a common courtesy point of view, we should introduce ourselves before making suggestions (based on need) and then asking permission, even if a consent for those tests has been given by the patient.

(3): Your dentist and hygienist should only provide services which are necessary. If the practice routine is to book all adult patients for a one-hour recall appointment, scaling should be billed on the basis of what treatment was needed and actually performed. If less than three units of scaling were performed the codes submitted and fees charged should reflect same.

Your dentist and hygienist should only provide services which are necessary.

It makes no sense to book everyone in for the same amount of cleaning as some people need much more and the danger is that, ‘thinking they’ve had their cleaning done’ the possibility of allowing supervised neglect to occur is great. Alas, I see this a lot in general practices.

Beware of having topical fluoride added as a matter of routine and make sure there is a justifiable necessity for this treatment, if you don’t want it, you are allowed to say so. As with all dental treatment, informed consent must be given by you prior to administering anything.

(4): Before you accept any dental treatment, ask, to satisfy yourself that what is being proposed does meet the standards of practice of the profession. If the dentist is proposing something outside of what is normally done, there is no reason that they shouldn’t, but you need to do due diligence, and it still has to be within the standards of practice.

Sometime ago I was involved in a case where an individual dentist developed a new technique, which by itself is OK. He developed a number of followers who all subscribed to a standard of treatment for this technique, which was within the general standards of dentistry.

He however did not always subscribe to his own guidelines, which then took him outside the standard of care expected of any dentist. This then made him liable for errors incurred and he had to stand accountable to the failure to maintain the “standard of care.”

If the area of practice involves a specialty, it would be prudent to consult with a trusted specialist colleague for a second opinion before implementing the technique.

If there is some controversy regarding the procedure, not only obtain the information you need to justify your treatment along with a supportive specialist, but as always, make sure you obtain informed consent from your patient before commencing treatment. Asking is always the first step.

(5): Although your dentist may be well qualified and experienced to provide multiple dental services while you are under deep sedation or general anaesthetic, be sure he or she complies with the applicable standards and to charge fees which would be seen to be reasonable in relation to the services provided.

Be sure to obtain and document informed consent pre-operatively and to have a protocol in place for obtaining consent should a change in treatment be needed during the appointment.

If you have dental benefits plan be sure to have your dentist submit (and keep a copy) a written pre-determination to the third party insurer/administrator so that all interested parties know the status of what is and is not going to be paid for under the plan. 

Please note too that in cases of sedation, it is recommended that two (2) qualified healthcare professionals, be they RN, doctor, dentist, anaesthetist, be present as well as a dental nurse. If the dentist is providing dental care someone needs to be reviewing your medical needs as you lose your protective reflexes during sedation, especially as that becomes deeper.

Possible solutions to dental fee confusion

Perhaps we should worry less about the codes and more about the treatment.

Having common procedure codes understood by dentists, patients and third-party dental benefits plan administrators alike appears to be of great benefit when there is a need to submit procedure codes for dental services performed.

Dentists should be advised as to what factors and expenses should be taken into consideration when setting the dental fees for their practices so that they can determine an appropriate fee schedule which is appropriate for their own practice.

Perhaps we should worry less about the codes and more about the treatment. We’ve just got so “used to” codes that we no longer see them for what they are and have become, simply a payment method.

If suggested fees are to be kept in fee guides, thought should be given to having a large range in “recommended or suggested” fees set out for each procedure code.

Instruction should clearly be given throughout the fee guide explaining how any dentist can create a customized fee schedule for his or her own dental practice depending on the circumstances applicable to the dentist’s specific situation, which is therefore fair to their patients, you.

Listing the factors, expenses and criteria which should be taken into consideration may be quite helpful in this regard.

Dentists should be wary of the consequences of inaccurate, improper and unethical claim form submissions.

Dentists should be encouraged to consult with the association(s) who created the fee guides applicable in their jurisdictions to ensure their questions are answered and their utilization of the fee guides is appropriate for the development of their own fee schedules for their offices (e.g. For Ontario dentists, The Ontario Dental Association, for BC dentists, The BC Dental Association.) 

Alas most associations ‘farm out’ this responsibility to commercial companies with their own agenda.

Please forgive my cynicism, but it has been my experience over many years and in several countries, most dental associations are more concerned about their own maintenance than that of their individual members, (unless it affects them.)

With greater understanding of the underlying concepts and use of fee guides, dentists can indeed bill as ethically as possible when relying on such fee guides in dental practice. I

t is up to you as a patient to know what is going on. Remember, short cuts don’t always lead to where you thought you were going!

Dr. Stephen Bray DDS

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