For a person who has a four-year Catholic private school primary education, four-year bachelor’s degree in Biology, four-year professional degree in dentistry,  two-year residency in Brooklyn and Queen’s impoverished neighborhoods and Trauma 1 centers, fifteen years worth of private practice and a two-year jaunt at Harvard’s Longwood campus researching dental public health and  “Adverse Events associated with Previously-Restored Teeth,  you’d at least begin to think this practitioner’s judgement was best for high-risk populations.


Not good enough for Delta Dental and Rhode Island Medicaid programs.  Yes. I said Rhode Island Medicaid programs.

Of all the programs to judge what is best for someone’s oral health… I think I’d prefer Mike Tyson over RI Medicaid for making decision about my teeth.

Threatened.  Fined.  What’s next?  Investigator Ritchie from the Rhode Island Attorney General’s office contacted a former employee insinuating that her career would be in jeopardy if she does not meet with him.  That comes across a bit harsh for a person who dedicated her first 6 years as a patient advocate and dental practitioner to the “under-served”, poor, socially-disadvantaged, distraught, and recovering populations of Cape Cod and Providence.

He reports through an obscure phone call (unknown) that he received a complaint (unknown) that Dr. Swann is forcing his employees to code for services different from what he performs.  I received this from my office manager yesterday.  What a way to end a good day of hard work!  Subsequently, a couple days later the first disenfranchised employee calls one of my current employees and tells her that she better do something to protect herself.

This all seemed ironic to me since I thought Medicaid should not being paying for anything as it pertains to teeth.  Its a complete waste of resources. It promotes the development of “drill mill” type of dental practices and most of the treatment paid for is unnecessary and mismanaged.   Everyone knows this.  Everyone has seen those “60 minute” TV show pieces on dentist exploiting medicaid resources.  I’ve always thought this was a joke and uninteresting since both parties were to blame.  The dentist is an idiot to think he would run his business based only on Medicaid reimbursements and the Medicaid system was to blame just given what it is.  Its a scam.  When developed its intentions were well, but as I know it now, its only there for the working class and immigrant populations as a point of formality.  Its exploited by most of its recipients.  I hate it mostly since I pay the idiot public officials to oversee it.


Oh well.  This is great.  We work 6-7 days deliver oral health care to high-risk populations affected by chronic diseases, drug abuse, domestic abuse, violent crimes, and developmentally challenged patients and someone at a desk says that we have broken contract. Hard to swallow for me but that’s our issue right now.

There is no suprise though. We’ve been audited by MassHealth, Delta Dental, and Rhode Island Medicaid in the past several years.

Now we are being threatened by “Mr. Ritchie” of the de facto Reservoir Dogs.

Our model of care is and always has been:

Delivering EFFICIENT dental care to high-risk populations.  

The state and private insurance companies do not promote efficient dental care.  Its not their model.  Its not expected and its not their intention.

The state and private insurance companies are practically the same entity now given all the regulations and subsidies. So I will refer to them as one and the same, the state.  

They have their own interests which outweigh the best interest of the patient.  This is fine since the funds come from taxpayers.  But as a professional in this field, the patient’s well-being is placed under my care.  I have dedicated my skills and career to deliver care to those who encounter the highest risk of problems.  I just so happen to utilize the state program is a means of communicate to people that we are here and there is an option of high-quality care. 

So why do I accept these methods of payment?  It’s low-cost advertisement and marketing for my business.  That’s the simple and probably best answer.

The reason “Mr. Ritchie” and “his informant” have a problem with Direct Pay Dental Care’s mission is because of a lack of knowledge about our level of care.  What we are discussing here is matter of efficiency and quality.  This has nothing to do with fraudulent claims, unethical treatment or unprofessionalism.  He wants it to be but he won’t find it here.  If you heard the message he left my former employee, it would take a five year old to know what type of person we are dealing with here.  Unscrupulous and unprofessional, the perfect person they would place on such a small case in the grand scheme of things.

We submit claims to RI medicaid and any other party for treatment involving all tooth surfaces involved in that treatment.   In a high-risk population,  its common to find rampant caries on multiple surfaces on multiple teeth and previously-treated teeth with symptoms . 

We treat all the surfaces for which we bill.

On the state’s fee schedule they want us to use amalgam.  They do not cover crowns or composite resin on back teeth in adults through RI medicaid. We have recently altered our office restorative protocol so that it accomodates the state’s preference.  However, it creates another inefficiency and access problem for patients who will probably need continued care.  This care may involve painful and fractured teeth which could have been prevented with a crown which our protocol would have suggested. 

Prior to the audit we did not use amalgam.  There are two reasons for this:  

1.  Technical limitations of the material:  Preparation designs for amalgam promote cracks, recurrent caries and pulpitis in teeth.  Undercuts and grooves hold the material in place which potentiate long-term fractures and leakage in the pulp space.   Over time teeth with amalgam restorations are weakened.  As a temporary I think amalgam still has a place for treatment  but in high-risk populations this poses a huge access issue for continued care.  Continued care would be what we suggest in the first place, a crown.  If crowned soon enough costly root canal therapy can be prevented and ultimately tooth loss which promotes continued periodontal and dental problems.  

Billing to RI medicaid for nominal reimbursement of an amalgam for the actual treatment of a full coverage crown is not against contractual agreements since its classified as operating under the professional judgment of the practitioner and meeting a higher standard of care than otherwise would have been attained.  All tooth surfaces reflected in the claim have been treated.  A full coverage crown is preventing what the amalgam ultimately would have caused.  Thereby,  RI medicaid and third-party colluders are and have penalizing Direct Pay Dental Care for a higher standard of care.   

2. Low efficacy in high-risk populations:  Amalgam procedures leave existing susceptible stained and hypo-(de-)calcified and cracks which can otherwise be treated effectively by a crown.  Its highly predictable that posterior teeth with fillings will more than likely incur one of these secondary problems, especially in high-risk populations.  A strong argument can be made that any dental restoration including amalgam or composite resin causes secondary problems such as recurrent caries, pulpitis and fractured teeth.   Therefore, its placement should be avoided unless patients present with symptoms.   

Direct Pay Dental Care strives to reduce the need of dental care per person by promoting better decisions through fair prices and more efficient dental restorations.  Our restorative protocol addresses short-term primary cause of dental problems as well as the problem resulting from the primary care. 

RI Medicaid and other third parties penalize us for doing this even though all surfaces billed for have been treated.