There may be trouble ahead…
Often when people think of getting into trouble as a dentist, it is the spectre of the ghastly mistake that floats into the mind: the procedure gone wrong with a single patient, the complaint to the General Dentist Council and the momentous consequences that ensue.
The reality is very different. Covering up and lying about such an incident will definitely not help your case but, faced up to squarely and honestly, the ‘procedure gone wrong’ experience is rarely disastrous. From both the USA and Australia there is now very considerable evidence that an early admission to the patient combined with an apology and a commitment to do your best to remedy the situation avoids more serious consequences in 98 per cent of cases.
There are, in fact, a myriad other much easier ways in which dentists can come to the notice of the GDC and the other authorities, and it is these that I am going to focus on in this series of articles on maintaining a trouble-free practice.
The first two trouble spots I want to deal with are fraud and the problems arising from fees charged. The second of these, generally having to do with overcharging, could be said to be a specialised subset of the first, but bearing in mind the undoubted complexity of the fee scale, it is worth looking at in its own right.
For many of the frauds that are discovered – either because it has come to light through the offices of the Counter Fraud Services (CFS) or after a patient complains to the GDC – the dentists responsible fall into one of two camps: those who deliberately set out with malice aforethought to profit from breaking the rules and those who stumble into it, usually through ignorance of the rules themselves.
Of course, there are some fraudulent acts nobody can ever claim to have stumbled into – no one, for example, invents 50 phantom patients by accident or claims, time and time again, fees and allowances to which they’re clearly not entitled. Those dentists – and thankfully there are only a very few of them – will eventually be found out and will rightly face the consequences.
But, for most of the rest, the infraction is usually of an inadvertent nature. A dentist might for example, claim 100 per cent of an allowance on the NHS, not realising that the proportion of private income they have earned has crept above the 10 per cent limit set out in the regulations. By not remaining up to date with the state of their accounts, that dentist will have unwittingly made a false claim – and strictly speaking, that’s fraud.
Lack of attention to detail can lead dentists astray in other ways too. Not specifying clearly on their laboratory tickets the type of metal they require for different appliances, for example, or not checking the goods received against those ordered. A laboratory could well end up supplying crowns with a non-precious metal, while the dentist has been merrily claiming a higher fee for gold or palladium.
Even if a laboratory were deliberately misleading a dentist, as the provider of the ‘appliance’ to the patient, the dentist remains responsible. In this case, good record keeping will be essential further down the line: you have to be able to show that you requested the precious metal and that you paid for it.
Poor record keeping is also the source of many an unwitting charging error. Without the documentation easily to hand, it would be a simple matter to charge a patient for a restoration that had been supplied within the last 12 months, when in fact that restoration effectively comes with a year’s free replacement. The dentist then processes the claim, which is perhaps paid out in full on the understanding that no money has been received from the patient on the second occasion, when in fact the reverse is true. The dentist has at best unwittingly overcharged the patient. Do that too often and you are likely to attract the attention of the ex-policemen who man the CFS.
On the other hand, it is quite possible that the dentist who charges twice in one year for such a restoration is not a chaotic keeper of records, but simply hasn’t got to grips with labyrinthine fee scales that have been agreed with the NHS. It is easy to see how this can happen. A young dentist, faced with a plethora of new experiences and responsibilities during their vocational training, might only half-ingest the detail of the fee scales. It is the experienced practice staff – both dentists and administrators – who keep them on the right track. That dentist might then go on to do a year in hospital or in the salaried services and forget the half they did learn. Unfortunately, back in practice a year or two later, trouble awaits.
I therefore urge all colleagues to make sure they – and their staff – are up to date with what is a complicated fee structure in terms of both the number of items and allowances, and the conditions that apply to them. Without that knowledge, you are at risk of sleepwalking into problems: charging patients for procedures that should have been free, misleading others about what is available on the health service and claiming allowances incorrectly. And unfortunately, ignorance is not a defence.
This may seem harsh but it is easy to understand why it has to be this way: one person’s ignorance is another’s calculated deception. Patterns of mis-charging, whether they are deliberate or otherwise, look the same when run through the CFS’s investigative computer programs.
I don’t plan to dwell on the inveterate fraudster, those ‘bad apple’ dentists simply looking to profit from their misdeeds. They know what they’re doing and will take the consequences. But within the ‘deliberate’ category of the dentist in trouble I would like to highlight two groups in particular, who I believe are basically good people who take a wrong turn and end up in trouble despite themselves: I shall call them the ‘justifying sinners’ and the ‘slip-sliders’.
The first group comprises those dentists who might say, for example: “I’m not prepared to do that on the health service – if I do, I’ll just get tuppence ha’penny, which is ridiculous for an hour and a quarter’s work”, when they are well aware they should offer the procedure in question. Alternatively, they might find themselves claiming a greater degree of difficulty for an extraction because of the amount of time it’s taken to talk the patient round, to check their medical records and phone their GP. In both cases – and there are many more just like this – they feel their actions are justified because “the system is unfair”.
And while I accept it’s true that some procedures aren’t very economic and that this can be frustrating part of the job, I don’t hesitate to point out that dentists are well rewarded for many other procedures and by a host of allowances. My advice to them is to take the rough with the smooth rather than put their fitness to practice at serious risk.
The ‘slip-sliders’ are those dentists who find themselves in such desperate straits that they resort to short-term deception in the hope they can buy themselves time. It could be the dentist who doesn’t realise they’ve had a bad financial year until their accountant reports the gory details six months after the event, or the one whose spouse has walked out and left them with three children; it could be the dentist who has got health problems and hasn’t been generating the same level of income but has continued to spend at the same level both personally and professionally and the bank manager has stopped their overdraft – oh, and the tax bill has just dropped through the letterbox.
Suddenly their life is in a mess and they’re tempted to do something foolish. So, they invent a patient or make a false claim. And very often, because the w
heels grind slowly, they get away with it at first. So they do it again. And again. But the reality is that they haven’t got away with it – and when the CFS investigators pay a visit, with a mass of evidence, it’s too late.
Over my years at the GDC, I came across many unlikely people who had got into trouble in this way and I urge anyone who finds the pressures of life closing in on them to pick up the phone to their legal adviser at their indemnity provider. I’m afraid they won’t send you a cheque but they will definitely help you navigate your way into calmer waters. There is also other help available from the likes of the BDA Benevolent Fund.
This advice to pick up the phone to your protection agency holds true for any dentist being investigated by the CFS – even those who are innocent, which is sometimes the case. Occasionally dentists have good reasons for showing particular patterns of claims that might appear fraudulent but which are not. And they may have all the paperwork to prove what they’re doing is okay, but they should still take advice.
It goes without saying that if it transpires you have deliberately transgressed, your indemnity provider can reserve the right not to defend you. But even in that eventuality they will likely put you in touch with suitable solicitors to represent you in the criminal court.
Financially, you will be on your own – the dental community isn’t always as one on policy matters but that’s something I’m sure you will agree is appropriate.
Hew Mathewson is a general practitioner in Edinburgh, a special adviser to the MDDUS and a former President of the General Dental Council.