Monique* has been working for dentists for twenty years as a billing clerk. During her career, she has seen “little things” and “accommodations” pass between the dentist and the patient so that the latter does not have to pay his share of the costs.
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A few years ago, Monique found a job in a firm (she prefers not to mention the name of the city where it is located) where fraud is commonplace.
“I came across someone who is an Olympic champion in this area,” she told me. Everyone in the office, or almost, is complicit in this way of doing things. There is no discomfort. It’s incredible. »
Monique can no longer bear to see this chain of fraud pass before her eyes and to be, in spite of herself, one of the links. She wanted to talk to me to clear her heart.
That’s good, I’ve been wondering about the existence of fraud in dentists’ offices for a long time. And how do we identify them.
Monique explained to me in great detail certain techniques used. First of all, frauds are divided into two categories: those that are done with the patient’s complicity and those that are done without their knowledge. Let’s start with the first.
“Descaling, which is part of the cleaning operations, is billed per unit of time [établi en fonction de la quantité de tartre]. To fill the percentage that is to be paid by the patient, the number of units is increased. When we receive the check from the insurer, we make a correction in the file of the client who has nothing more to pay. »
The descaling trick is a “classic”, according to Monique. There is also that of the filling. You should know that a tooth has five surfaces: the four sides and the top. A cavity can affect more than one surface.
So that the customer does not pay the difference, we will add a surface. But in reality, the dentist only worked on the surfaces that really needed it. When the check arrives, we apply the same principle.
Monique*, billing clerk in a dentist’s office
Even for very expensive interventions, there are various tricks. Monique gave me the example of a crown that costs around $1700. “Let’s say you have to have two and you’ll have to pay half. You cannot charge for a third crown, because you have to send an X-ray to the insurer. What are we doing ? We create a new treatment that the insurer cannot verify, such as the addition of an occlusal plate that we suggest to those who grind their teeth. That’s $1,000 passing easily. »
Monique sees passing cases of mouths in very poor condition. Treatments can be up to $6,000 or $8,000. “So that mom or dad can receive the many interventions, the dentist invents fictitious treatments in the mouths of other family members. »
This employee is overwhelmed to see the number of patients who ask their dentists for sleight of hand so they don’t have to pay. “For some, it’s downright a norm,” she says. They don’t expect anything more than that. »
The other category of fraud targets false care that is billed without the patient’s knowledge. “As part of a deep cleaning, teeth may require curettage, explains Monique. The dentist inflates the bill by charging for teeth he has passed over quickly. These are treatments that require a lot of time. When we see that the dentist does the work in a short time, we can see that the invoice does not correspond to the intervention. How can a patient know what has or has not been done in their mouth? »
Monique is going through a situation that she describes as “nightmarish”. She therefore contacted the Office of the Syndic of the Order of Dentists. She felt “heard”. But she was told that if she wanted to file a complaint, she had to do so openly and provide as much detail as possible. She hesitates to take this step.
“I’m afraid I won’t be able to find a job in this field anymore,” she told me. Who wants to report? After that, you’re burnt out. »
I spoke with the Dr Mario Mailhot, Director of the Office of the Syndic of the Order of Dentists of Quebec. He understands this difficult situation very well. “But to properly investigate, we need a lot of details, including the names of the patients involved. You can’t go fishing and land like that in a dentist’s office. »
In addition, employees who file a request for an investigation should be aware that if the case ends up before the Disciplinary Board, they may be called to testify.
“You can’t make omelettes without breaking eggs”, adds the Dr Mailhot.
The steps that tend to demonstrate that a dentist is committing fraud are long and complex. For example, to prove that the work carried out does not correspond to the sum claimed, it is necessary in particular to compare an X-ray of the patient with the details which appear on the invoice sent to the insurance company.
At the Office of the Syndic, investigations are classified into two categories: complaints related to one or more offenses of a behavioral nature (lack of integrity related to billing schemes) or of an economic nature (disagreements over fees that may be deemed inaccurate or abusive).
Requests for inquiries come mainly from patients. Cases of fraud are reported by staff members. Finally, reports come from insurance companies. The Dr Mailhot told me that some insurance companies have algorithms that can detect fraudulent behavior in invoices.
Monique’s testimony strikes the imagination. But you should know that with 5,400 dentists in Quebec, few requests for investigation are filed and a tiny amount of cases end up before the disciplinary council.
In 2020-2021, the Order of Dentists received 70 investigation requests of a behavioral nature and 32 of an economic nature. Some files include both categories.
But only a small handful of them go before the disciplinary council. Three files, submitted in 2019-2020, and seven others, in 2020-2021, passed this stage. They are currently being studied.
At the Canadian Life and Health Insurance Association (CLHIA), I was told that they do not collect data on the number of cases of fraud detected.
The penalties can be serious for a professional. But also for the patient who lends himself to this game. He risks losing his insurance plan, being fired and ending up with a criminal record.
In Quebec, personal insurers pay health benefits (disability, medication, etc.) and dental benefits totaling $7.9 billion (2020 sum). A small percentage of frauds represent large sums, recalls the CLHIA.
In other words, the more people ask for “accommodation” from their dentist, the more the latter agrees to be complicit, the more this will have an effect on the amounts that employers and employees will have to pay for their plan.
The word “collective” in the term collective regime, that is what it means.
* Fictitious first name