Is this dentist trying to scam the insurance company?

Dr. Hall,
I had three crowns done – upper and lower first molars on the left side, and lower right second molar. They were porcelain fused to high noble metal, insurance code #D2750. For $150 each, the dentist suggested I upgrade to crowns with added porcelain, so there would be no black line on my gum line in the future. On his advice I agreed.

When I got the insurance paperwork I noticed there was a charge on all 3 crowns for pulp cap direct, insurance code #D3110. Nothing was ever said to me about the pulp cap direct, so when I questioned it, his office insurance lady said that the insurance takes care of that, and whatever they don’t take care of she will write that portion off at no cost to me.

Then, two months after getting the crowns, the one on the lower right fell off. To my surprise it was a very very small partial crown. I questioned why I paid for an upgrade when there was no gum line involved, since it was such a small crown. The insurance lady told me the crown was all porcelain and the metal would have shown, if the upgrade hadn’t been done. I also asked why there needed to be a build up and why it needed pulp cap direct. She told me he had to build up the tooth and the root was almost exposed which does not make sense to me. The dentist re cemented the crown and charged my insurance company, but did not charge me. I would appreciate your feedback on my issues. Thank you so much for your time.
– Tony from California

Tony,
I don’t know because I can’t verify any of this, but all of this sounds awfully suspicious to me, like this dentist has a scam operation to milk everything he can out of the insurance companies.

And you.

I’m an accredited cosmetic dentist who saw a lot of appearance-conscious patients, and I never did porcelain margins or anything like that for esthetic purposes on lower molars, and two of these teeth you reported to me were lower molars. One was a second molar. Even if there were a black line there, no one would ever see it. In my own mouth, I have gold crowns on both my lower second molars and no one knows but my dentist and me.

And for a crown to fall off after two months? In twenty years, I never had a crown that I did fall off.

You said that the crown that came off, when you looked at it, had no metal and the insurance lady told you it was all porcelain. That makes sense, since you say it was a very short “partial crown.” Being all porcelain, it could be bonded to the tooth, which would make it stay on. But it didn’t stay on. Furthermore, the procedure code you quoted me was for porcelain fused to high noble metal (i.e. porcelain fused to gold), which would get a higher reimbursement rate from the insurance company than what it appears was actually done. And it certainly sounds like the dentist just made up that all these teeth required direct pulp caps. A direct pulp cap is a serious situation where the decay goes down to the pulp of the tooth and the dentist puts a special coating directly on the pulp of the tooth to try to save it without doing a root canal treatment. That tooth should then be watched to make sure it heals well before doing anything major like a crown. A protocol that would make sense would be to do the buildup and wait a couple of weeks to make sure the tooth isn’t sensitive and responds properly. And I would certainly expect the dentist to tell you about this at the time to tell you to let him know if you have any sensitivity afterward. If you did, then further attention would be needed. If you didn’t, then the dentist is going to want to get credit for heroically saving your tooth and saving you from needing a root canal treatment.

And that this was done on all three teeth? That strains credibility.

And the notion that the practice would write off whatever the insurance company didn’t pay, that’s an indication that this procedure is all an invention to get a little more money from the insurance.

I think this is worth an investigation by the insurance company. I’d report to them that you weren’t aware of any pulp caps. And you could also report your suspicions to the California dental board, if you have a mind to.

I’m not saying this dentist has done anything wrong—I’m saying it’s suspicious and worth looking into by the insurance company and by the dental board. If alerted, the insurance company and the dental board can demand to see the actual records and x-rays of these finished procedures and can check other patients to see if this dentist can back up his claims of what he has done.

Dr. Hall

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