ETHICS

 

A patient suggests fraudulent behaviour

 

 

P Govan

Correspondence

 

 

A patient complains that she 'hates her partial denture" and wants a 'porcelain bridge' just like the one the dentist made for her best friend. Her partial denture is now fifteen years old, is poorly fitting and is not aesthetically pleasing. Her present oral health condition would tolerate either a fixed or removable partial denture. The patient has medical aid in terms of which benefits for prosthodontics is limited to a maximum allowance of R3000.00 per annum. The dentist agrees to send a pre-estimate and authorisation for a fixed prosthesis and couple of weeks later the Scheme rejects the application for authorisation but with a decision that authorisation is given for a removable partial denture.

The patient is upset and insists that the dentist complete the fixed prosthesis and then submits a claim for a removable partial denture. She would then pay the balance of the account. The practitioner explains that this would be illegal and unethical, but the patient again insists that that her decision be followed or she will go to another dentist who is willing to oblige. This seemingly simple request by the patients may have serious ethical and legal implications.

This case presents ethical problems relating to (a) several treatment options and informed consent; (b) submission of dental claims and (c) unreasonable requests by patients.

There are two treatment alternatives proposed: fixed or removable partial denture therapy. In other cases, informed consent may involve a myriad of treatment options, the choice of materials, techniques, all compounded by the preferences of the patients.

The above case also provides an opportunity to discuss third party funders and their effect on dental practice. The patient may question the judgement of the dentist if a treatment recommendation is rejected by the funder even though their membership is on the basis of a benefit plan only. More often than not patients do not understand their dental plans or benefit limits. They question why they must pay more for a fixed prosthesis. Most practitioners believe that the patient is entitled to the best dentistry regardless of what his/her Scheme offers, as funders cannot dictate dental treatment, only the benefits allowed.

Patients may request their dentist to mispresent treatment in order to maximise dental benefits, a request that challenges the honesty and integrity of practitioners.

The Health Professions Council's ethical rules on probity implies that a dentist will, at all times, act with integrity to protect patient and public trust in the dental profession.¹

Dental professionalism allows dentists the independence to perform their duties with integrity and can be defined by qualities such as ethical principles of beneficence, respect, integrity, truthfulness and placing the needs of patients first and as "excellence and accountability" (including continuous education and providing health-care services of a high standard.²

These ethical principles should guide the decision-making process and actions of the dentist. Society's trust in dentists is dependent on the integrity of the individual dentist and the integrity of the dental profession as a whole. If a dentist's behaviour does not conform to the HPCSA's ethical and professional code of conduct, it is seen as unprofessional conduct, compromising quality health-care and risking patient safety.

Dentists should also always act with integrity in all financial interactions with patients and medical schemes. The HPCSA states clearly that "health-care practitioners shall not charge or receive fees for services not personally rendered, except for services rendered by another health-care practitioner or person registered in terms of the Health Professions Act (Act No. 56 of 1974), which regulates the particular profession and with whom the health-care practitioner is associated as a partner, shareholder or locum tenens". The HPCSA also cautions health-care professionals on over-servicing patients, referring to unnecessary tests, scans, procedures or care.³

It is important to bear in mind that funders use investigatory probes to identify health-care professionals suspected of fraudulent activities.

Dentists should ensure they act with probity and professionalism when submitting claims and never submit inappropriate, false or inflated claims. If such claims are made intentionally, that is regarded as fraud, in which case even indemnity organisations are unlikely to provide assistance; and the relevant health-care practitioner will also probably be investigated by the HPCSA.

Medical aid fraud is classified as "personal misconduct that does not directly relate to the practice of dentistry". Nowadays, patients are more informed of their rights and responsibilities and the HPCSA encourages them to report doctors who are unprofessional in their conduct. Furthermore, it is the responsibility of health-care practitioners to report any activities relating to fraud or misconduct.

To protect their independence and the credibility of the profession, dentists should act with professionalism and probity. Unprofessional behaviour should not be tolerated.

 

References

1. HPCSA, General Ethical Guidelines for the Health Care Professions, Booklet 1.         [ Links ]

2. HPCSA, Ethical and Professional Rules of the Health Professions Council of South Africa, Government Gazette.         [ Links ]

3. HPCSA, Guidelines on Over-servicing, Perverse Incentives and Related Matters, Booklet 5.         [ Links ]

 

 

Correspondence:
Punkaj Govan
Legal advisor, SADA
E-mail: pgovan@sada.co.za