Dental fraud. A dental consultant's view

Area of Science:

• Dental Insurance
• Healthcare Economics
• Public Health Policy

Background:

• Current dental insurance plans, often based on
• cost plus
• ,

Purpose of the Study:

• To analyze the financial sustainability of current dental insurance models.
• To examine the impact of new dental codes and high-cost medications on insurance plans.
• To discuss the potential consequences of fraudulent practices on the availability of dental benefits.

Main Methods:

• Analysis of insurance plan structures and fee schedules.
• Review of case examples involving new dental codes and expensive medications.
• Discussion of market trends in the dental insurance industry.

Main Results:

• Employers and unions struggle with increased costs for procedures like bonded amalgams.
• High-cost medications for conditions such as migraines place significant burdens on drug plans.
• Dental insurance carriers are facing financial difficulties, leading to consolidation and market exits.
• Certain dental procedures, like specialized endodontic examinations with radiographs, incur costs exceeding typical plan allowances.
• While most dental practitioners are honest, fraudulent activities by a few can lead to negative repercussions for the entire system.

Conclusions:

• The current dental insurance model is financially unsustainable.
• Increased costs and potential fraud threaten the availability of dental benefits for employees.
• Urgent reevaluation of dental insurance policies and practices is necessary to ensure long-term viability and patient access to care.