Reviewing dental claims is a regular part of our job at MKC Medical Management. But the work isn’t as clear cut as it might seem when you’re dealing with a cracked tooth or gum lacerations. They often take a lot of sleuthing.

Let’s look at one case we reviewed. A man was reportedly struck on the left side of the chest. The claimant reported that he fell and injured his left knee and chest. Buried in the same records, however, was a costly dental restoration plan.

Based on the facts, I wondered how the claimant could justify such a thing. So, I started with the emergency department records.

Checking the facts

I reviewed everything and cross referenced the alleged event facts and ALL of the objective data, including the lab tests and diagnostic results.

I looked at pieces of information tucked in the emergency room nurse’s triage notes, what the EMS documented, the treating physician’s exam and the discharge orders.

In other words, I looked at everything. I really focused on the subjective complaints and reported information  In fact, I reviewed everything three times!

And, guess what?! NO oral trauma was documented. There was NO subjective complaint regarding oral, dental, teeth, gum pain or trauma. In fact, the claimant self-reported NO head trauma.

Furthermore, there was an entry documenting “no oral trauma.”

None of the hallmarks of oral trauma were there:  No blood, no laceration, no missing or cracked teeth. NO oral pain. Instead, the exam stated, “Oral mucosa, pink and moist.”

Wait, no oral trauma?

So, I am thinking, why did the carrier send this file?

I kept digging. Because nothing is really obvious, is it?

I discovered that the records reported that the claimant received chiropractic care about three days after the incident date. But there was no mention of facial or oral trauma in the chiropractic notes. Considering the account of the event and that the description of all of the other injuries was very detailed, it was odd.

Then, more review … this time the dental records.

The injured man was seen by the dentist the day of the alleged incident. More mystery, as there was no documented problems. I concluded that he must have been seen before the accident as well.

Next, I pulled out the dental billing statement. There was NO billed return visit until four weeks after the alleged accident.

Alert, alert!

I then went back to the handwritten dental documentation. The corresponding notes clearly documented NEW findings involving MULTIPLE teeth:  A fractured bridge, damaged  crown, cracked/loose teeth and a FRESH laceration around the gum with an associated a tooth fracture.

These findings were significant and a HUGE RED FLAG! A person with so much dental damage – and pain – would likely not wait four weeks to seek evaluation or treatment.

And, while some of this might be a mixed bag of acute and non-acute findings, those findings clearly did not fit the alleged mechanism of injury and the claimant’s report that he suffered no facial and head trauma at the time of the accident.

 

Final recommendations

I recommended that BEFORE payment consideration be made, the carrier should request additional documentation that supported the initial mechanism of injury and lack of oral injury. I also recommended asking the treating dentist to explain the current findings in light of a four-week treatment gap.

We often review claims with dental injuries. These can be tricky. The information documented in a dental record is often presented very differently than a medical record.

There may not be the familiar “dictated” note. The daily visit notes are often handwritten abbreviations and acronyms known only to dentists and hygienists.

Sure, there are other components of the dental record, including medical and dental histories, diagnostics and X-rays, personal information and electronic records, among others. But this information is often not submitted with a liability claim.

Getting to the truth takes ingenuity, a willingness to dig and a practical understanding of trauma care.