Fraud leads to cut in dental insurance

Dentists are prescribing unnecessary treatment and claiming money from insurers for procedures they did not perform.

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ABU DHABI // Dentists are prescribing unnecessary treatment and claiming money from insurers for procedures they did not perform. The Health Authority-Abu Dhabi (HAAD) last week announced the large numbers of violations by dentists led to it dropping full dental insurance cover for Emiratis at private centres.

Beginning today, Emiratis will have to pay 50 per cent of dental costs under the Thiqa programme, which has 500,000 members, unless they are treated at public hospitals or clinics. An investigation by The National revealed huge discrepancies in treatments recommended to patients by private dentists in the capital. A reporter who visited three clinics was told by one dentist he only needed his teeth cleaned at a cost of Dh300, while another advised him to replace a crown and 14 fillings at a total cost of Dh41,010 (US$11,165).

The health authority did not respond to questions about the discrepancies. Dr Jad Aoun, the director of third-party administration at the national insurance company Daman, said the wide variety of treatments that dentists could provide gave them more opportunity to defraud the system. "With dental care, we can never know whether the patient really requires the treatment since we cannot examine the mouth of each patient," Dr Aoun said.

"In planned treatments it is left to the discretion of the dentist and the choice of the patient. There are lots of options." Dr Aoun said Daman had become aware of certain dentists recommending the most costly treatments, some of which might not be necessary. When an insurance company is covering treatment costs, some dentists see fit to "inflate the bill", he said. Another of the biggest problems dental insurers face is the muddied distinction between cosmetic and necessary treatments.

"You cannot have a system where you can control cosmetic procedures," Dr Aoun said. "It is uncontrollable. In some instances of orthodontics, you cannot draw a clear line between a cosmetic and necessary procedure. "Also, a dentist may recommend a very costly treatment when the much cheaper one would actually be better, just to boost their income." Insurers are reluctant to provide large sums for dental work because of the discretion dentists have in determining treatments. Under Daman's Global Plan, its most comprehensive policy, there is a maximum yearly limit of Dh5,000. Daman will cover 80 per cent of the cost but every non-emergency treatment must be authorised in advance. X-rays, extractions, composite fillings, root canal treatments and prescribed drugs for all these treatments are the only things the company will cover. The same rules apply for the UAE Plan, but the annual limit is Dh2,500. Dr Aoun said Daman had noticed a number of different ways Thiqa and other insurance schemes were being defrauded by dentists. "Patients know they have coverage for limited services, so if they wanted a cosmetic procedure like teeth whitening, they ask the dentist to send a pre-authorisation or a bill request to us for something we do cover, which totals the price of the whitening," he said. "We agree and then the dentist gets paid for whitening the teeth." Each time a dentist seeks pre-authorisation from Daman they must include the procedure on a map of the teeth, marking exactly where the work needs to be done. Daman checks these maps to look for any discrepancies, such as a treatment request for a filling a tooth that had earlier been authorised to be pulled. "We are getting more and more dental expertise within Daman to check for things such as this," Dr Aoun said. "In the beginning we said 'no' to dentists applying to work in Daman, but now we are using them more and more." Daman performs spot checks in private hospitals and is expanding them to more private dental clinics. If it finds evidence that a dentist has been committing fraud, it can drop the clinic from its network. That would mean the clinic could ultimately lose Daman clients. "We need to find a balance between control and trust," Dr Aoun said. "We are not judging all dentists on the behaviour of just a few. We also do not want the provider to lose money, but we need to get rid of the perception that lying to an insurance company is not a serious matter. It is."