An interesting article titled “You want me to do what?” written by Douglas Auld appears in the March 2016 issue of JADA. The article discusses a patient who has an an abscess on a mandibular right third molar which requires extraction. The treatment was done in December and the patient had already used their full benefits from their dental insurance for the year. So the patient suggested to the dentist to bill for the extraction in January and also suggested to file it as a surgical extraction and apply the difference to his balance.
The article asks if it is ethical for dentists to do any of this. The article states that a dentist has a duty to communicate truthfully with third parties. It says
“A dentist who submits a claim form to a third party reporting incorrect treatment dates for the purpose of assisting a patient in obtaining benefits under a dental plan, which benefits would otherwise be disallowed, is engaged in making an unethical, false or misleading representation to such third party.”
Therefore the dentist should file the claim with the correct date of service or wait until January to perform the treatment.
The article says
“A dentist who incorrectly describes on a third party claim form a dental procedure in order to receive a greater payment or reimbursement or incorrectly makes a non-covered procedure appear to be a covered procedure on such a claim form is engaged in making an unethical, false or misleading representation to such third party.”
Therefore the dentist should file the claim with the correct treatment performed.
The article says that the dentist would also be also would be engaged in fee splitting if they credit the difference in fees to the patient’s account. So having the patient profit from the treatment is not allowed.
Therefore a dentist is not required to do everything that a patient requests and is still be ethical. It is not clear how many patients requests dentists to bile certain treatments in certain ways that bend the truth to their insurance companies.