Dental schemes in need of check-up

More than 10 per cent of the claims made by private dentists could be inappropriate or fraudulent, writes Sara Burke

A SERIES of unpublished reports on the free dental scheme for adults reveals that in excess of 10 per cent of the €85 million budget is paid out by the HSE on inappropriate or fraudulently claimed payments by dentists in private practice.

Despite knowledge by senior officials in the Department of Health and the HSE of these payments in the dental scheme, no action has been taken.

Reports have been commissioned as far back as 2002 making recommendations on how best to put checks in place for dentists who wrongly claim fees or carry out inappropriate procedures under the Dental Treatment Services Scheme (DTSS).

Dr Paul Batchelor of Oral Care Consulting (OCC) was commissioned by the Department of Health to assess and make recommendations on probity assurance (the checks in place) in the dental care sector in three separate reports.

In a final summary report commissioned and submitted to the Department of Health in February 2009, and seen by The Irish Times, Dr Batchelor said “probity assurance is not a static process but a continual war against those who would make inappropriate use of [in this case] public funds”.

It is understood that there is concern within the Department of Health about what some officials have termed the “increasing opportunity for fraudulent payments”.

It is also believed there is a recognition that fraudulent and what have been termed “misappropriated claims” under the DTSS need to be acted on quickly.

The free adult dental scheme has had significant extra demand on it in 2009 compared with 2008, with over 30 per cent extra or €9 million spent on it during the first six months of 2009. The rising expenditure in this scheme has resulted in increased attention from the Department of Health to its delivery and to where potential savings could be made.

According to the HSE Performance Report for August 2009, the increasing cost of the scheme is a combination of higher numbers of people with medical cards who are entitled to free dental care, greater use of the scheme and more dentists participating in it.

The DTSS is one of three dental schemes operated by the State. The other two schemes are free dental care for children and special needs groups (the Public Dental Scheme ), which is also run by the HSE, and the subsidised dental care for more than two million people who pay PRSI contributions (the Dental Treatment Benefit Scheme ), which is run by the Department of Social and Family Affairs.

In both the DTSS and the DTBS, the HSE reimburses dentists on a fee-for- service basis. It is in these schemes that the possibility of inappropriate and fraudulent claims by participating dentists exists. In the PDS, where dentists are paid a salary as HSE employees, no such opportunity exists for improper claims. The budget for the PDS and the DTBS is estimated at €60 million and €68 million respectively for 2009.

The reports acknowledge while only a small number of dentists are deliberately making inappropriate or fraudulent claims, there is considerable opportunity for bad practice and manipulation of the schemes when there are no checks in place, as is currently the case.

The fraudulent and inappropriate claims occur when dentists claim for an activity that did not actually happen or claim for one treatment when in fact a simpler (and cheaper) treatment was carried out.

For example, there is a very high rate of surgical extractions (complicated tooth removal) in the DTSS. Dentists get paid a higher rate for complicated surgical extractions than simpler ones, but there is a disproportionate rate of complicated surgical extractions in the DTSS.

Prior to 2007, when there were checks and balances in place and the scheme asked for X-rays to prove a surgical extraction had taken place, the rate of complicated surgical extractions declined.

Another example of fraudulent or inappropriate behaviour is when a dentist may claim for eight fillings and a clean, when just two fillings and a clean were carried out. There have been cases where dentists claimed to fill every tooth of some of their patients. There have also been some instances whereby dentists have reimbursed the HSE for work claimed but was not actually carried out. However, no penalties have been imposed on these dentists, despite financial reimbursements being made – and the reimbursements have been kept out of the public domain.

The first Batchelor report in 2002 found there “was a lack of information on the magnitude of the existing problems in DTSS arrangements . . . accountability in the system was poor and arrangements that existed to deal with perceived breaches in probity were inadequate”.

The 2007 report found considerable progress had been made, especially in relation to the establishment of the Examining Dentist Scheme, but further progress was required which involved investment in both personnel and training in probity assurance.

The 2009 report highlights how the checks and balances in place for fraudulent and inappropriate claims have deteriorated notably since 2007. In the 2009 report, Batchelor states that “not only had the system failed to develop further [since 2007] but had actually failed to maintain levels previously achieved. OCC would argue that the current levels of probity [checks] are very weak. Indeed . . . probity assessment has fallen below the level identified in the initial report [in 2002].”

This report details how the probity assurance group put in place to oversee the scheme has been inactive since early in 2007, and that the group did not meet or operate during 2008 and 2009. It says the HSE section with responsibility for the scheme, the Primary Care Reimbursement Scheme (PCRS), has withdrawn its participation from the probity assurance group.

Batchelor also says there is “currently no examining dentist scheme in place”, which he identifies as a crucial part of any probity scheme. He is also scathing of HSE management, saying that to achieve savings from inappropriate payments “would require a substantial commitment on the part of the HSE, which it has failed to show since 2007”.

Batchelor explains the problem of having checks in place. “The importance is that if checks are stopped, (a) it is more difficult to restart them and (b), it announces to the target population [dentists] that no one is looking and so encourages inappropriate behaviour.”

The probity scheme for dental services, on hold since 2007, was intended as a pilot scheme “that could be applied to pharmaceutical and medical payments where public expenditure is much higher”.

Attempts to contact Dr Batchelor yesterday were unsuccessful.

Expenditure across these schemes in 2009 is estimated at €2.9 billion. If rates of inappropriate and fraudulent claims in the dental schemes were applied to the other schemes, such as the pharmaceutical and medical payments schemes, it could be argued that tens of millions of euros are being misappropriated.

This article is available on . It also appeared in The Irish Times' Health Supplement on 20 October 2009