Dental Injury Claims: The Good and The Bad

Dental Injury Claims: The Good and The Bad by Dr. Kal Klass As the lead reviewer for dental injury claims in Washington State, for the Department of Labor and Industries, I consult for and review many of these submitted claims. The two most common dental injury claims are of two major types: 1. Claims with the Department of Labor and Industries 2. Dental malpractice claims The Department of Labor and Industries pays for dental treatment related to any injury in the employee’s place of employment. In other words, if anyone is injured while working for their employer, L and I will cover any dental related expenses in full. To become a provider for L and I, start with this web address: https://lni.wa.gov/. Dental claims are usually reimbursed for fees above what most insurances cover. However, you should be aware of the following nuances: There is a WAC (296-20-110) which expressly prohibits coverage for any non-injury related teeth or TMJ injury. Sometimes, dentists (most often from corporate clinics) try to submit claims to include other teeth not injured with the teeth that were injured. In fact, unfortunately, many claims are submitted for teeth injured when there were no injuries to teeth at all. As a dentist and a reviewer for L and I, you may imagine that it is quite easy for me to determine the true cause of a dental problem by looking at the ‘pre’ and ‘post’ injury records. Some dentists assume that another dentist will not be reviewing these claims, but it is the opposite: a dentist almost always is the one reviewing these L and I dental injury claims. Your most secure guarantee for coverage is to ensure there was no pre-existing (pre-injury) damage or pre-existing condition related to the claimed teeth AND to only submit a treatment plan for the damaged teeth, not for any others. Many patients who make claims and have never seen a dentist, may see this as an opportunity to get as much free dental work as possible. The dentist needs to be up front in explaining to the patient which teeth would be seen as injured in a recent claim. If any dentists question becoming an L and I provider or if anyone ever has a question pertaining to their L and I claim, you are welcome to call or email me for a consult; there is no fee for that, and my contact info is below. Your best record for documenting the injury is always an intra oral photo. In this day and age, I am always amazed how many dentists still do not use intra oral photos to document dental problems. All I can say about this is that the newer cameras are so cheap and easy to use, there is no reason not to use them. I often decline coverage for cracked teeth because the dentist only provided an x-ray, and I cannot see any cracks on most of these x-rays unless it is a fractured root. Overall, x-rays are inferior to intra oral photos for many claims sent to any insurance company as well as to L and I. I have never had a claim denied by any insurance when submitting photos from my practice. I have had claims denied when only submitting x-rays, as we all have. Malpractice claims are usually quite different, as you may imagine. They most commonly occur when one dentist disparages another dentist if some dentistry has failed for any reason. There is often a strong incentive for the disparaging dentist since they stand to gain a lot financially if redoing dentistry for a patient. Please remember that the ADA Code of Ethics strictly prohibits disparagement of another dentist. That means that whenever you see any kind of failed or poor-quality dentistry, you should feel obligated to fix it, but please don’t ever assume the previous dentist did something wrong or convey that to the patient. I have worked for many malpractice cases in which disparagement of another dentist occurred, and 100% of the time, whenever the judge or arbitrator is aware of this, they favor the defendant/dentist, sometimes by quite a lot. I always document this for the judge or arbitrator whenever I see it in the records. Since the topic of malpractice claims is more involved for discussion, it will not be discussed further here. We can address this in another future article which can explain how best to avoid malpractice in your office. Kal Klass DDS, Member of Peer Review Committee klassdds@gmail.com