Most dentists participate with insurance carriers and have negotiated contracts with insurers so patients can have their care covered. Insurance companies generally have guidelines regarding the types of services they will cover and the circumstances under which a dentist is permitted to bill for patient services.
In some cases, however, there are questions about whether a procedure is truly necessary or whether a dentist is improperly billing for procedures which do not need to be performed. When these questions arise, there are circumstances under which a dentist could be accused of insurance fraud and circumstances under which a dental license could be at risk.
If you are accused of improperly billing an insurer, it is important to explore all of your options for defending against the allegations. You should have professional help with dental license defense, as you may need to make persuasive arguments to show why the care you provided could be viewed as medically necessary rather than as an attempt to pad the bill.
Insurance Fraud Accusations and Your Dental License
Recently, Kron 4 reported on a dentist who had his license suspended and who was facing 28 counts of felony insurance fraud. According to news reports, the 66-year-old dentist had first obtained his dental license back in 1976. He allegedly carried out procedures which were found to be medically unnecessary. A total of 28 patients came forward, while others reportedly chose not to cooperate. Approximately 10 of the patients also filed civil lawsuits against the dentist, in addition to cooperating with the civil case.
The investigation began when another dentist purchased the practice of the man accused of insurance fraud. The new dentist went over the old dentist's records and reportedly found unnecessary operations had taken place, including unnecessary crowns and root canals. This dentist who had taken over the practice also filed a civil lawsuit.
The complaints made about the dentist performing this unnecessary procedures prompted a criminal investigation, criminal charges, and the suspension of the dentist's license. The outcome of the case is pending.
In situations like this where a dentist has been accused of providing unnecessary medical treatment to make insurance claims, it is imperative to determine whether the treatments were actually subjectively unnecessary or whether there is simply a difference of opinion regarding the need for treatment.
Some dentists may be more conservative than others when it comes to performing complex procedures or providing treatments. Other dentists may opt for a more aggressive approach to maintaining oral health. No dentist should lose his license over accusations of insurance fraud if there is simply an honest disagreement regarding whether or not a particular procedure should have been performed. A dentist accused of intentionally performing unnecessary procedures to get more insurance payouts has a lot at stake, and should get proper legal advice right away to defend against these serious accusations.