Dental Problems After Treatment Plan Was Changed, No Notice to Patient

[Maxomom]

My question involves medical malpractice in the state of: California
Two years ago had extensive dental work done for the treatment of periodontal disease. Treatment plan and subsequent charges for service submitted to me and to my insurance company indicate that a number of bone grafts were done in order to stabilize loose teeth due to bone loss in my gums. Have since learned that some of the bone grafts in my treatment plan that my insurance company and I paid for were never completed and I was not informed of a change to my treatment plan after the fact. I am now losing a tooth where a graft was supposed to be done. 1) isn't this insurance fraud to charge for a service that was not rendered and 2) is this dental malpractice since I now am losing a tooth due to their failure to execute the plan as agreed?

Thanks!

[Mr. Knowitall]

The fact that the dentist submitted a plan that was approved by the insurance company does not, of itself, mean that the plan was followed or that the dentist billed for work not performed when he deviated from the plan. Sometimes during surgery, new issues arise or become apparent and plans change. I expect that your medical record includes a report from the surgery describing how the procedure was conducted and any differences from what was expected preoperatively. You are, of course, free to bring the issue to the attention of the insurance company for them to investigate, as if they overpaid they may well want to recover their money.

When you asked your dentist about why he didn't perform a bone graft at that location, what did he tell you?

[Maxomom]

Thank you for your reply.

I know that the dentist billed for the bone grafts exactly as they were stated in my treatment plan as I received the standard EOB (Explanation of Benefits) from from my insurance company when they paid the dentist.

I have not confronted the periodontist about his change of plan. When I first became suspicious that something was wrong, his colleague, a general dentist in the same practice, showed me a post-op x-ray of one of my molars that was supposed to receive a graft and there was no bone material in the root of the tooth. This tooth was scheduled for a post-op crown which the general dentist said that he could not do because the tooth was not stable. When I questioned why after recently having had extensive work in that area the tooth was still unstable, his face turned white and he gave a very lame and contrived excuse. I am sure that he realized what had happened and covered for his colleague. I then checked all of my paperwork from the dental group and realized that this tooth was scheduled for a graft and it didn't happen. Had the general dentist been honest that the treatment plan must have changed, then I might have gone back for a better explanation. The tooth that I just lost was also scheduled for a graft that didn't happen as I have just had x-ray's from another dentist that clearly confirms which grafts were done and which were not.

If there is no legal issue here, then I will contact the dental group and ask for my money back and let them know that I am reporting them to my insurance company.