Depends on Where you Sit!

• Brian Barrett, DDS •

J Can Dent Assoc 2000; 66:184

Sitting at my desk, I open the file and read through the history. The patient is a 77-year-old man in good health who has kept much of his natural dentition, albeit heavily restored. The claim form is appended, and the only treatment listed is for porcelain fused to metal crowns on the 11 and 21. No endodontic treatment, posts or cores - just two crowns - and I am supposed to determine whether the government - for whom I am a dental consultant - will cover the cost.

barrett.jpg (19845 bytes)I open the envelope containing the radiograph that you see below and wonder. There was no periodontal treatment suggested nor replacement of either of the existing restorations, and there’s no post in the left central and no mention of the periapical lesion within 1 mm of the apex on 21, nor is there mention of the possible perforation on the mesial aspect of 11 as evidenced by the radiolucency at the apical third of the root. The cost for the treatment is over $1,200. Is it a covered service or not?

But another time, much earlier, I sat in another office at another desk opening another envelope, this one containing a letter from some insurance company that had received a “request” from a third-party administrator for radiographs. I recall thinking, “What do they need them for? I (being duly licensed in Canada) have decided in my best clinical judgment that the tooth needs a crown to be properly restored, and just who is this pretend dentist to ask for a radiograph? Do the CDA guidelines not say that the only decision to be made is whether the service is covered or not? What a nuisance! They are just trying to wear me down so that they don’t have to pay for the crown. Who the hell do they think they are! Probably no one but a clerk ever sees them anyway.”

It really does matter where you sit.
There’s an old saying about walking a mile in someone else’s shoes before you have too much to say. Good advice, as I have changed hats and have the privilege to see over 5,000 claims a year for dental treatment from all areas of this country. I am more than pleased with what I see from 90% of the practitioners working on the clients we serve, but I have to say that the other 10% leave me scratching my head at times. The radiograph I have included in this piece was submitted to substantiate a claim for crowns. It’s the type of thing that every dental consultant in Canada sees every day. The employers and administrators know it is going on, yet dentists as a group have the gall to question an insurer’s right to refuse to pay for the treatment. As dentists, we may say that refusal to cover treatment is a problem, because insurers are diagnosing without actually seeing patients, but I think that most of you looking at the radiograph published here do not need to see the patient to decide on this case. More importantly, how do we assure that such a treatment isn’t done with some poor soul paying for it out of his own pocket.

It is a classic case of killing the golden goose, and we as a profession are going to have to step up and take some of the responsibility for assuring that such treatments don’t happen. True, the carriers can file a complaint, but is that their job? We are supposedly a self-regulating profession, yet what do we regulate other than access to the job market? I have heard the argument that these inappropriate treatments are isolated cases, but would you send a radiograph like this to any other dentist you know, asking for an opinion on crown placement? I really think that these poor sods believe that they are doing the right thing... and God help anyone who lies in their chair.

I write these things to stir up the pot and I hope that others will react and get a little annoyed at what some are doing to the profile of our profession. When the third parties grow tired of the abuse - both the quality of treatment provided and the misrepresentation, for financial gain, of what was done - we will see the end of third-party payments. When patients and the government learn of the level of abuse of privilege and the level of incompetence, we will lose the right to self-regulation. Both scenarios may not be a bad thing for the patients, but from my other seat, I can’t believe that they will be good for the vast majority of the profession. Let’s not let a few bad apples ruin the rest of the barrel.

Dr. Barrett maintains a private practice in Charlottetown, P.E.I. He is executive director of the Dental Association of P.E.I.

The views expressed are those of the author and do not necessarily reflect the opinion or official policies of the Canadian Dental Association.