You completed treatment of Dr Marion Kaye, the noted art historian, 5 years ago. You felt a special satisfaction with her final result and valued her appreciation of your effort because she was one of the most fastidious adults you have ever treated. Your staff related her attention to detail to her profession, in which she specializes in identifying imperfections in restorations of valuable artwork. When you notice her name on the day sheet as the last patient before lunch, you know that your lunch break will be short.
Dr Kaye arrived in her typical fashion: 20 minutes before her appointment, impeccably groomed, and expecting to be seen promptly. Although you had discharged her over 3 years ago, your documentation confirms that you had said that her maxillary left lateral incisor might move despite devoted retainer wear. You suggested a bonded maxillary retainer, but she had declined. Her maxillary retainer is now ill-fitting, and she admitted to wearing it at night intermittently. “I’d like you to correct the tooth, please,” she requested in a near-demanding tone. In an extended conversation, you gave her several options for doing so and advised her of your fee. She chose to have her maxillary Hawley remade to accomplish her objective.
Soon after she left your operatory, your staff told you that Dr Kaye requested that you submit the cost of her replacement retainer as a “night guard,” because she knows that her insurance carrier will reimburse for a night guard rather than a retainer. Your business manager explained that this is inappropriate, but Dr Kaye would not concede and left in a huff. Your manager pleaded that the retainer be considered a night guard so that “we can appease Dr Kaye to avoid her attitude.”
Third-party reimbursement can be a sensitive subject for the provider and the patient alike. Since most patients do not understand the provisions and intricacies of third-party reimbursement, exploration of a patient’s insurance coverage by the orthodontic office staff is 1 way to reduce a patient’s barriers to initiating treatment. Although we all want to act as advocates for our patients, misrepresenting insurance codes or modifying dates of service to comply with coverage deadlines—either on our patients’ behalf or for our own remuneration—is illegal. As importantly, it violates the trust that is expected of us as professionals.
Among other qualities, professionalism involves mastering a level of expertise and skills that benefit the community. By entering into a profession, the dentist also inherits the obligation to act with a level of integrity that benefits individuals and society. We are trusted to do what is right on behalf of ourselves and others without the need of third-party validation. This is in contrast to those working in other fields such as the construction industry, in which every component of a project is scrutinized by inspectors. As professionals, we make the commitment to place the well-being of patients ahead of our own personal gain. That is a hallmark of a professional.
Insurance coverage should never dictate or influence a treatment plan. Doing so threatens our autonomy to assign the appropriate level of care to our patients. Although it is the prerogative of the orthodontist and not the insurance carrier to prescribe a treatment plan, it is the responsibility of the orthodontist to respect the established guidelines of insurance coverage.
In the case of Dr Kaye, no patient should manipulate us to act in an unethical manner. If the appliance you have prescribed is not a night guard but is instead a corrective appliance that is excluded from insurance coverage, the patient needs to know that she will be responsible for its cost. You might need to terminate your relationship with her if she does not respect your autonomy. This can be essential to maintaining your integrity and upholding the professional values that typify us as orthodontists.