Significant Lawsuit Regarding Specialists Practicing General Dentistry - Could this change things?

[Miley Cyrus.]

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So apparently an Arkansas Orthodontist is suing Arkansas in federal court over the law that specialists can't practice general dentistry. I was always under the impression that specialists were allowed to do GP, but couldn't advertise as both a specialist and a GP? This doesn't seem like some small lawsuit and this guy (Ben Burris, he seems like a big shot in dentistry and seems to have done really well being in ortho for only 10 yrs) looks like he's got the money to fight this. Apparently lots of GPs and a OMFS complained a lot to the board. Looks like a serious turf war gone legal lol. (Links to the article are below)

http://www.arkansasmatters.com/stor...e-dental-board-i/59054/jk6hZZKz-kasXPX3VI3sBA

http://www.ij.org/AR-dentist-law

History and Background behind how the case came up
http://www.arkansasbusiness.com/article/94758/dentists-orthodontists-at-odds-over-cleanings?page=all

My questions for you guys:
1) What do you guys think of this? He started some cleaning program and he seems to be doing very well. He apparently has 100+ employees (seems like he is running a big dental mill on the side. only employes hygienists in his GP practice). You think the guy is genuine or just wants more money?
2) It says in the article, "“Seven other states have laws like this one". So does this mean that a majority of states allow specialists to practice general dentistry, because I was under the assumption a majority of states are against this??
3) Suppose we see a ripple effect like this guy says it might cause. How do you think this would change things in dentistry? I can only see corporate dentistry as the ones benefiting from this because after all, which private practice general dentist is going to refer his patients to a specialist who practices GP on the side??
4) A GP doing a specialist procedure is subject to extra scrutiny. What about a specialist doing GP procedures? Is there no diff in liability?

 

[Miley Cyrus.]

bump..............................

 

[dmdluffy]

Let him do all the general dentistry he wants. No GPs are going to refer to him and he's going to be starved for patients. GPs are king in dentistry.

 

[Shunwei]

Let him do all the general dentistry he wants. No GPs are going to refer to him and he's going to be starved for patients. GPs are king in dentistry.

Then there is also the issue of how much general dentistry he can really do and whether he has the equipment/supplies. This guy must really be starving to think about doing so because, in theory, specialists make more per hour than GPs. Is that one of the main reasons many chose to become a specialist?

 

[Ar2]

If I read the article correctly, it doesn't seem to me that he is wanting to do root canals, implants, & crowns. He simply wants to be able to provide basic hygiene cleanings if needed. As someone who had braces previously, I would prefer this as it would save me time & money. The wires being already removed would allow for a good cleaning while in the office. But that's the issue, right?.. Money, no?.. Are GP's really that ****ed up about letting a hygienist provide oral health care just bc it's in a Orthodontist's office?.. Bc when I go to the dentist he never does **** anyways. The hygienist does it all. It's funny they don't seem to mind becoming "weekend specialists", yet are up in arms at the thought of a certified DENTIST & specialist providing the most basic of treatments so that patients are provided a service they need. It baffles me. He just wants to be able to provide cleanings to his patients. It's not like my 50 year old mother is going to start going to the orthodontist to get her teeth cleaned. I mean come on. If they are that worried, legislate a law that allows for ortho's to provide cleanings to current patients only, as part of their orthodontic treatment.

 

[Ar2]

Then there is also the issue of how much general dentistry he can really do and whether he has the equipment/supplies. This guy must really be starving to think about doing so because, in theory, specialists make more per hour than GPs. Is that one of the main reasons many chose to become a specialist?

And I highly doubt he is starving. He owns one of the largest ran orthodontic practices in the country. Why is it always about $$$?.. The guy just wants to be able to offer cleanings to his patients. How dare he!!!

 

[Shunwei]

And I highly doubt he is starving. He owns one of the largest ran orthodontic practices in the country. Why is it always about $$$?.. The guy just wants to be able to offer cleanings to his patients. How dare he!!!

Like I said before, 99% of the evils we see comes down to $$$. In this case, if he is looking to give cleanings to his patients, he is clearly infringing on GP territory. It's pure greed.

 

[Ar2]

Like I said before, 99% of the evils we see comes down to $$$. In this case, if he is looking to give cleanings to his patients, he is clearly infringing on GP territory. It's pure greed.

Pure greed... Really?

 

[gn4]

Like I said before, 99% of the evils we see comes down to $$$. In this case, if he is looking to give cleanings to his patients, he is clearly infringing on GP territory. It's pure greed.

This is what I don't get. I haven't started dental school yet, so I may be naive, but I don't get what the big deal is. If he wants to provide cleaning, why should that be bad? You say he is infringing on GP territory, but couldn't you say the same for a GP who takes Ortho CE cases to do Ortho for his patients instead of referring out?

 

[Miley Cyrus.]

What I don't understand is how this would pass through Stark law/anti-kickback laws. Wouldn't such an arrangement as this guy's be illegal?

I would be fine with this as long as Medicaid of Arkansas did not pay for ortho treatment. If it did pay for ortho, I think it is quite obvious as to how unethical this practice could become and is proof the dentist is a total slime-ball. The guy could very easily have Medicaid orthodontic patients in his practice and then bill for cleanings without anyone being adequately able to asses whether the cleaning was needed. It is obviously a breach of medical ethics, is unfair to the unsuspecting patient, unfair trade practices for the GPs (who probably would not be reimbursed at a specialist rate if they were to do ortho treatment in their practice), and unfair to the taxpayer who will see his money be wasted for unnecessary procedures being done on his dime. I looked at the site for Arkansas and it says "The following dental care is covered for children who have ARKids First A or Medicaid:.....Orthodontic care such as braces, if needed for medical reasons". For medical reasons? Who is deciding whether the braces are for medical reasons or for cosmetic purposes?

 

[Shunwei]

This is what I don't get. I haven't started dental school yet, so I may be naive, but I don't get what the big deal is. If he wants to provide cleaning, why should that be bad? You say he is infringing on GP territory, but couldn't you say the same for a GP who takes Ortho CE cases to do Ortho for his patients instead of referring out?

Well for one if specialists decide to pursue generalist care they might as well forget about referrals from any generalists nearby. The tradition has always been that specialists rely on generalist referrals for their business. The GP in dentistry is not only the first line of defense like the primary physician on medicine but since there are fewer specialized disciplines in dentistry many GPs also have the training to do a lot of the specialist procedures. Many patients also prefer the GP to do certain specialist procedures because the GP fees are cheaper.

As for what about GPs doing ortho cases, well some are indeed doable like the easier Invisalign cases. However, I do think some GPs overreach themselves with bracket-based systems. But I have already touched upon this in my previous posts.

 

[diasIItema]

It is unethical and unprofessional to advertise as a specialist and then practice general dentistry; it's in the ADA professional code of conduct (and even Dental Decks for those studying for NBDE 1!). You cannot charge specialist rates for specialty procedures and then perform general dentistry as well. General dentists, on the other hand, are encouraged to perform any aspect of dentistry they are qualified to do and competent to do. That is the advantage of general dentistry - you charge lower rates and provide broader service, whereas with specializing you must accept the fact that you're sacrificing areas of dentistry in order to SPECIALIZE in one or two specific areas and charge the fees that specialty demands. Hygiene brings in a LOT of revenue; hygienists together make 1/3 of collections in the average practice (which is why they make BANK).

 

[Miley Cyrus.]

It is unethical and unprofessional to advertise as a specialist and then practice general dentistry; it's in the ADA professional code of conduct (and even Dental Decks for those studying for NBDE 1!). You cannot charge specialist rates for specialty procedures and then perform general dentistry as well. General dentists, on the other hand, are encouraged to perform any aspect of dentistry they are qualified to do and competent to do. That is the advantage of general dentistry - you charge lower rates and provide broader service, whereas with specializing you must accept the fact that you're sacrificing areas of dentistry in order to SPECIALIZE in one or two specific areas and charge the fees that specialty demands. Hygiene brings in a LOT of revenue; hygienists together make 1/3 of collections in the average practice (which is why they make BANK).

👍
Amen to that. This guy just seems greedy.
lol if he wins his lawsuit, then if I were a GP I would sue the state and say that it is unfair business practice for Medicaid to reimburse an orthodontist at a higher rate for orthodontic services than a GP who performs ortho services. Hope this guy loses his lawsuit or scores a Pyrrhic victory.

 

[Sublimazing]

It is unethical and unprofessional to advertise as a specialist and then practice general dentistry; it's in the ADA professional code of conduct (and even Dental Decks for those studying for NBDE 1!). You cannot charge specialist rates for specialty procedures and then perform general dentistry as well. General dentists, on the other hand, are encouraged to perform any aspect of dentistry they are qualified to do and competent to do. That is the advantage of general dentistry - you charge lower rates and provide broader service, whereas with specializing you must accept the fact that you're sacrificing areas of dentistry in order to SPECIALIZE in one or two specific areas and charge the fees that specialty demands. Hygiene brings in a LOT of revenue; hygienists together make 1/3 of collections in the average practice (which is why they make BANK).

So this comes up all the time....and there is never a definitive answer... Would you mind posting a link to where it says this in the ada professional code of conduct?

 

[Shunwei]

It is unethical and unprofessional to advertise as a specialist and then practice general dentistry; it's in the ADA professional code of conduct (and even Dental Decks for those studying for NBDE 1!). You cannot charge specialist rates for specialty procedures and then perform general dentistry as well. General dentists, on the other hand, are encouraged to perform any aspect of dentistry they are qualified to do and competent to do. That is the advantage of general dentistry - you charge lower rates and provide broader service, whereas with specializing you must accept the fact that you're sacrificing areas of dentistry in order to SPECIALIZE in one or two specific areas and charge the fees that specialty demands. Hygiene brings in a LOT of revenue; hygienists together make 1/3 of collections in the average practice (which is why they make BANK).

Well said, phrased it much better than I did bro.

 

[Sublimazing]

I can understand why GPs would never refer to the specialist advertising as general dentist...but what makes it unethical?

 

[wb1]

he seems like a big shot in dentistry and seems to have done really well being in ortho for only 10 yrs) looks like he's got the money to fight this. Apparently lots of GPs and a OMFS complained a lot to the board. Looks like a serious turf war gone legal lol. (Links to the article are below)

two words: greed & ego.

 

[gn4]

It is unethical and unprofessional to advertise as a specialist and then practice general dentistry; it's in the ADA professional code of conduct (and even Dental Decks for those studying for NBDE 1!). You cannot charge specialist rates for specialty procedures and then perform general dentistry as well. General dentists, on the other hand, are encouraged to perform any aspect of dentistry they are qualified to do and competent to do. That is the advantage of general dentistry - you charge lower rates and provide broader service, whereas with specializing you must accept the fact that you're sacrificing areas of dentistry in order to SPECIALIZE in one or two specific areas and charge the fees that specialty demands. Hygiene brings in a LOT of revenue; hygienists together make 1/3 of collections in the average practice (which is why they make BANK).

so just out of curiosity....let's say I specialize, but I never advertise that I'm a specialist...am I then allowed to practice general dentistry?

 

[Screwtape]

so just out of curiosity....let's say I specialize, but I never advertise that I'm a specialist...am I then allowed to practice general dentistry?

Yes, super common with prosth in my area.

 

[tinman831]

so just out of curiosity....let's say I specialize, but I never advertise that I'm a specialist...am I then allowed to practice general dentistry?

I believe that you can in this case.

 

[Ferneezy]

^^^ but in such a scenario, said specialist must bill GP rates regardless of what they do, right?

sounds like cutting off your nose to spite your face.

 

[sgv]

I believe that you can in this case.

so can an orthodontics trained dentist advertise as a GP then offer both general dentistry and keep all the ortho cases and maybe even mention to the patients in person that they have orthodontics training?

also can a general dentist refer a patient to another general dentist (how about referring to the same guy mentioned in the first scenario who has orthodontics training but advertises as GP. could you refer a patient to this guy who advertises as a general dentist?)

what qualifies as advertising? is hanging up a certificate of orthodontics, prosth, perio, etc. in your office considered advertising? is word of mouth advertising like telling patients in person?

these questions are probably specific to each state...

 

[Miley Cyrus.]

^^^ but in such a scenario, said specialist must bill GP rates regardless of what they do, right?

sounds like cutting off your nose to spite your face.

This is I think is the most important question.

From what I've read, he had a site for his little cleanings-side op and this is what showed up:

1. “The first time I called I Just Want A Cleaning.com for an appointment, I learned something unexpected – something that surprised me but also made me feel more confident that I was in the right place. The team at I Just Want A Cleaning.com told me they accept my insurance** and were more than happy to file it for me but they recommended that I save my dental insurance benefits for dental work instead of spending it on cleanings. They said they wanted me to have my full dental insurance benefit in place in case I needed crowns, filings or other dental work that is much more expensive than a cleaning. I was blown away. Where else can you find a business who’s looking out for your best interests AND encourages you to make an INFORMED choice about your insurance?”

So it looks like this guy has the patient pay up-front lol.

 

[Miley Cyrus.]

I just looked at DentalTown and saw the thread (link to Dental Town Thread is Below). A majority of dentists are vehemently against him, think he is very unethical, and know that he's selling snake oil under the guise of "Oh, I'm just trying to help the poor". He likes to say he wanted to offer "cheap, affordable cleaning services" to the poor, but apparently his rate his higher than normal lol. He charges $99 for prophy lol. He also pays his dental hygienists $17/hr apparently lol. What a farce. This man is just as despicable a the corparate dental mills (he owns 11 ortho practices), and Lutheran Medical (opens up a new pediatric residency program like every week). He is wrapping up this whole thing in "oooh I'm such a good guy trying to help the poor". I hope he loses his lawsuit, gets his license suspended, and is investigated for the rampant overbilling that is obviously going on his practice. A lot of GPs feel that he is trying to smear GPs and I agree with them. He also wrote an article bashing GPs (http://thehill.com/blogs/congress-blog/healthcare/194400-keeping-your-primary-care-dentist-honest)

http://www.dentaltown.com/MessageBoard/thread.aspx?a=11&s=2&f=2573&t=226903&pg=4&st=Arkansas&g=1
http://www.dentaltown.com/MessageBoard/thread.aspx?s=2&f=135&t=226894&pg=2

 

[charlestweed]

so can an orthodontics trained dentist advertise as a GP then offer both general dentistry and keep all the ortho cases and maybe even mention to the patients in person that they have orthodontics training?

also can a general dentist refer a patient to another general dentist (how about referring to the same guy mentioned in the first scenario who has orthodontics training but advertises as GP. could you refer a patient to this guy who advertises as a general dentist?)

what qualifies as advertising? is hanging up a certificate of orthodontics, prosth, perio, etc. in your office considered advertising? is word of mouth advertising like telling patients in person?

these questions are probably specific to each state...

Why would a GP refer his/her patients to another GP office for ortho treatment and risk losing his/her patients to another GP office? There are a lot of ortho CE classes that adequately train the GPs to do ortho. I am sure the GPs who went to these classes can handle many ortho cases very well. However, these GPs can’t advertise their practices as “practice limited to ortho.” This is the reason why I chose to spend additional 2 years to do ortho residency. By limiting to ortho, the GP offices in the area know that I am not their competitor. By limiting my practice to ortho, I am able to get referrals from several GP offices and have larger patient pool than a GP office that does ortho. My wife did her perio residency for the same reason.

 

[DrJeff]

Speaking as a GP here. When I refer out a patient to my local ortho for tx. I'm essentially giving him/her a "check for $x" (X can vary a bunch from location to location around the country, but were talking thousands of dollars here), very often for most ortho patients (adolescents) the amount that the ortho will receive for that 2 yr average treatment time is more than the cumulative amount that me as the GP will bill for restorative work over the time that patient (and I'll just assume that I started seeing that patient at age 2 and will see them through their early 20's for arguements sake here) is under my care. Hey, we as dentists DO run a business here.

Now if that ortho wants to do the patients cleanings over that treatment time, that 3 to 4 cleanings worth of production (which can depending on the time of total ortho tx and the amount billed for a cleaning) be over a $1000 of production lost for my office, let alone a number of extra open spaces to be filled in my office's hygiene schedule over that time (which these days may not be so easy to fill in many parts of the country). Not good from the perspective of the GP.

Additionally, you as the GP are the "quarterback" for the patient's care team. I want to be seeing that patient in ortho tx every 6 months to follow the progress of the case to see if I need to have a chat with the ortho about why he/she is moving a tooth in a certain way or if any additional planning and/or tooth movements is/are needed to set a case up that might involve congenitally missing teeth, etc.

Lastly, one of the comments made earlier about it being "easier" to clean with the wires removed, just doesn't hold much water the vast majority of the time. Any decent hygienist can easily clean around and arch wire and/or remove the o-rings, clean, and replace the wire/o-rings the vast majority of the time, especially in straight NiTi wire cases as are used so much of the time now.

Bottom line is this ortho WILL have a referral problem, and that will hurt eventually the bottom line of that practice far more than the income generated through cleanings will add

 

[yappy]

Speaking as a GP here. When I refer out a patient to my local ortho for tx. I'm essentially giving him/her a "check for $x" (X can vary a bunch from location to location around the country, but were talking thousands of dollars here), very often for most ortho patients (adolescents) the amount that the ortho will receive for that 2 yr average treatment time is more than the cumulative amount that me as the GP will bill for restorative work over the time that patient (and I'll just assume that I started seeing that patient at age 2 and will see them through their early 20's for arguements sake here) is under my care. Hey, we as dentists DO run a business here.

I agree with most of what you said but do you think that the bold is an appropriate mindset to have? You're not doing the work, you're not financing the work, nor are you an orthodontist. How is that you're cutting him a check?

 

[Sublimazing]

I can totally understand why GPs wouldn't refer out to this guy...but I still don't understand why it's unethical.

 

[ortho lurker]

***NEWSFLASH*** This orthodontist probably wasn't relying on GP referrals for new business, that's why he was trying to find other means of bringing new patients into his office. Quite honestly, if an orthodontist is reliant on GP referrals to survive in today's market, then they better find a new business plan because that doesn't work anymore with more GPs doing Invisalign and short-term ortho or hiring in-house. Unfortunately, orthodontists now have to market to the community and get patient referrals just like GPs to stay open. There's more to this story because he is trying to create these dental hygiene centers for the poor at his locations.

 

[ChrisM07]

I agree with most of what you said but do you think that the bold is an appropriate mindset to have? You're not doing the work, you're not financing the work, nor are you an orthodontist. How is that you're cutting him a check?

I see your both points. I guess he means that he chose that particular orthodontist to refer to so in a sense, he is sending him a case that will bring him in extra money. I guess you could call that patient, or the case itself, a 'check'. Now if that orthodontist goes and does work that the referring GP could have done after the ortho treatment was over, then there is no reciprocity there.

 

[DrJeff]

I see your both points. I guess he means that he chose that particular orthodontist to refer to so in a sense, he is sending him a case that will bring him in extra money. I guess you could call that patient, or the case itself, a 'check'. Now if that orthodontist goes and does work that the referring GP could have done after the ortho treatment was over, then there is no reciprocity there.

I agree with most of what you said but do you think that the bold is an appropriate mindset to have? You're not doing the work, you're not financing the work, nor are you an orthodontist. How is that you're cutting him a check?

By "cutting him/her a check", the reality is that most of the time, when you as a GP refer a patient to a specialist, they will go, and they will go to that particular specialist, since you as the trusted GP, have the patient's best intent in mind, and also are trusting of the quality of work that that particular specialist will do for that patient. When talking ortho, most parents, and an increasing number of adults, often expect that referral, and realize that they will be paying for that orthodontic treatment. Even in my rural corner of CT, where both geographically and economically I'm about as far from the "CT Gold Coast" where all the Wall Street big whigs like to live, well over 80% of the referrals that I make to my local orthodontist will choose to have treatment. So when I say "cutting him/her a check" all that I mean is that when I hand that patient (or that patient's parent) the referral slip to my local, trusted orthodontist, I'm pretty sure that 4 times out of 5 that referral slip will translate into 5-6k of production during the 2 years on average of treatment time for his/her office. I am not literally cutting them a check, just metaphorically.

 

[DrJeff]

***NEWSFLASH*** This orthodontist probably wasn't relying on GP referrals for new business, that's why he was trying to find other means of bringing new patients into his office. Quite honestly, if an orthodontist is reliant on GP referrals to survive in today's market, then they better find a new business plan because that doesn't work anymore with more GPs doing Invisalign and short-term ortho or hiring in-house. Unfortunately, orthodontists now have to market to the community and get patient referrals just like GPs to stay open. There's more to this story because he is trying to create these dental hygiene centers for the poor at his locations.

In some areas of the country (read as high population urban and suburban areas) that might be the case, but there are still plenty of areas where the specialist is HIGHLY reliant on the GP referrals for their practice, even with many GP's doing invisalign

 

[arkenstone]

So this comes up all the time....and there is never a definitive answer... Would you mind posting a link to where it says this in the ada professional code of conduct?

Here's the link. Page 5, section 2.B.1

It's not exactly a prohibition -- just more of a 'team player' thing to encourage an atmosphere of professional collaboration -- a worthwhile goal for the ADA. Loss of business should not affect a GP's impulse to get the patient in touch with the best knowledge and experience.

My interpretation is: you shouldn't hard sell your care over the referring dentist's care -- you're basically undercutting the very judgement and consideration that sent them to you in the first place. The patient has to "reveal" a preference for your care.

Section 2.B.2 starts out as if it's going to say that a specialists shouldn't practice general, but it doesn't really say that, and I find it vague. I think if you earn the patient of your own accord and your local colleagues are well aware that you also practice general, I don't see why the specialist shouldn't practice general if they want.

 

[tingting]

The point is that as a specialist you are "special" because you focus all your efforts, education and treatment on a very narrow scope of dentistry. Once you deviate from this, you are in effect no longer practicing at the highest level of your specialty. If you are doing general dentistry, you are no longer a specialist, period. If I send a case to a specialist I am expecting greatness. Otherwise whats the point? GP's with advanced training are able to offer any specialty care short of general anesthesia and maxillofacial surgery.

Also for those of you that don't seem to understand this... alot of ortho is no longer dependent on referrals, rather they advertise directly on billboards etc. Ortho has more corporate influence than the other specialties these days.

 

[Silent Cool]

n=1 but, when I sought orthodontic treatment about 6 years ago, I did not ask my dentist for a referral. Instead, I perused yelp and googled "my city, orthodontists" and simply did my own research. I didn't rely on anyone or anything except the market to tell me who was the best.

Also, a large factor in my decision was proximity to where I was working at the time. So even if my dentist had recommended some amazing person across town, I would have sought someone closer out of convenience. Frankly, I would do the same thing when seeking any kind of specialist or general dentist care.

I can't imagine simply taking anyone's referral and not checking what else the market offered me in a given area.