The assigned case has several inconsistencies and significant mistakes that go against insurance policies and guidelines.
According to the form that Mr. Pro Crastination provided, it was stated that the patient got a comprehensive preventive dental examination. In reality, Mr. Crastination got several procedures done for him in the dental clinic. These include taking periapical films, diagnosing, and determining the source of pain in the tooth, performing an emergency pulpotomy along carrying out post-operative instructions. Previously, Mr. Crastination has not gone to the office for the annual examinations, and the procedures done by Dr. Giles were performed in a state of emergency. Therefore they did not count as scheduled office visits.
Preventive exams are not meant to diagnose, treat, and evaluate existing problems. Since the visit was entirely considered a medical treatment, it does not meet the requirements of an insurance provider and may not be billed as preventive; therefore, not be paid. Besides, taking periapical films may not fall under preventive care, if they require oversight and if specific operations were carried out on the matter.
It is evident that Mr. Crastination simply wanted his dental services covered by an insurance company. Nevertheless, for the services provided for him by Dr. Giles, he will be required to pay toward a deductible, coinsurance, or even a copay. In this case, Dr. Giles should pull out the dental records and report the results accordingly to the patient’s insurance company and notify them of the procedures done and at what cost.
Ethically and morally speaking, Mr. Crastination has acted dishonestly and has not been transparent about him getting diagnostic care. This kind of situation should be handled appropriately, because the insurance companies may get a person in trouble if the services are misused inappropriately.