The dental profession has been warned for over two decades in peer reviewed literature of the ability and ease to manipulate digital dental radiographs. Violators may have nefarious purposes. Possibilities include deceptions and misrepresentations to the insurance industry, dental patients, Medicaid third party administrators (TPAs), state dental regulatory boards, as well as civil, criminal, and administrative law proceedings.
Alterations of digital x-rays may go far beyond adjustments in image contrast for enhanced diagnostics, or removal of artifacts for educational purposes. Radiographs may be modified and reworked with utilization of a variety of software products such as Adobe Photoshop to fabricate inauthentic images. Digital images may be artificially transformed to indicate dental caries, missing tooth structure (e.g., cusps and incisal angles), periapical radiolucent lesions, falsified endodontic obturations, fractures, misrepresentations in crestal bone levels, etc.
The only limitations are seemingly the creativity of the perpetrator.
Apparently, dental image manipulations were not much of an issue, as so few if any cases had been discovered and adjudicated.
Reality hit hard with a January 13, 2021, ruling in US District Court for the Court of New Mexico, in William C. Gardner, DDS vs. Charles Schumacher, DDS, et al.
Gardner brought a legal action against the New Mexico Board of Dental Health Care, to stay revocation of his dental license. It was affirmed by the federal court ruling of Judge James O. Browning that Gardner, among numerous other violations, altered dental digital x-ray images for purposes to defraud an insurance carrier.
“The Insurance Fraud Complaint alleges that “Dr. Gardner submitted multiple claims for a porcelain/metal crown” to Delta Dental, and that Dr. Gardner attached a “radiograph … [that] appears to have been manipulated in some form to indicate advanced caries.” NM State Court Complaint at 60 (attaching images of the alleged manipulation).”
“1. A pre-op x-ray/radiograph is an x-ray/radiograph taken before any dental procedures are performed on the tooth.
2. The second x-ray/radiograph submitted to Delta Dental is a photo-copy of the first x-ray/radiograph submitted to Delta Dental:
a. The first x-ray/radiograph is properly cut diagonally at the corners as would be expected in a copy of the original x-ray/radiograph whereas the second shows the outline where the diagonally cut corners were, but the second x-ray/radiograph shows 90 degree corners.
b. Neither x-ray/radiograph show that one of the cusps have been removed. Both x-rays/radiographs show both cusps in place are identical except for the decay in the second x-ray/radiograph.
c. Both x-rays/radiographs are taken at the exact same angle which is physically impossible unless the second x-ray/radiograph is taken immediately after the first x-ray/radiograph is taken.”
The federal court affirmed evidence that a pretreatment radiograph was manipulated to indicate bogus dental caries (tooth decay).
After a lengthy evaluation, the US court denied Gardner’s motion for a restraining order stay on revocation of his dental license.
EXAMPLES OF DENTAL FRAUD WITH DIGITAL X-RAYS UTILIZED
In a previous interview with Dentistry Today, an industry expert explained how their Pearl AI software was responsible to detect fraudulent billings, when x-rays were a key factor in determination of patient eligibility of benefits.
- “One provider used the same toothless panoramic image to get insurance approvals for expensive dentures for almost 40 patients.”
- “One provider submitted the same patient’s full-mouth x-rays 18 times for more work and to re-seek insurance approval.”
- “Several providers have been using the same x-rays to get insurance approvals for patients of radically differing ages, which Pearl calls fairly flagrant fraud that was going undetected.”
However, the AI software was not formatted to detect manipulated digital x-ray images. The current detection software only discovered identical radiographic images were exploited.
On March 10, 2022, Wisconsin dentist, Scott Charmoli was convicted by jury trial in federal court. Charmoli was found guilty of five counts of healthcare fraud and two counts of making false statements related to healthcare matters.
The dentist drilled away patients’ tooth structure, such as tooth cusps, and subsequently took x-rays of his efforts.
These radiographs were fraudulently submitted to insurance companies as pre-treatment x-rays.
“The evidence showed that Charmoli performed far more crowns than most dentists in Wisconsin, ranking in, or above, the 95th percentile of crowns performed in each year from 2016 to 2019, according to data from just one insurance company. The evidence also showed that Charmoli billed over $4.2 million for crown procedures between 2016 and 2019, and that he performed more than 700 crowns each year from 2015 to 2019. In each of 2015 and 2016, Charmoli performed over 1000 crown procedures.”
In neither examples provided by Pearl or in the dental fraud case of Charmoli were digital x-rays altered.
Regardless, it is abundantly clear that deviant dental providers will go to extensive lengths to generate ill-gotten financial gain.
PRIOR WARNINGS
As early as 1994, the medical and dental communities were alerted to the feasibility of computer generated enhancements and manipulations to alter scientific content in digital images (digital photographs, digital x-rays, digital CT scans).
Israeli researchers demonstrated how digital CT scans and MRIs could be manipulated to aid in potential insurance fraud, ransom ware, and cyberterrorism.
A paper from the Journal of Endodontics stressed the challenges faced to validate authenticity of digital images. Mishandling and abuse can occur with ease. A standard authentication process is needed, but not yet readily available.
Researchers have gone to the extent of examining if skilled and seasoned dentists had the ability to detect manipulated digital radiographic images. Their study concluded, “Malicious changes to dental X-ray images may go unnoticed even by experienced dentists. Professionals must be aware of the legal consequences of such changes. A system of detection/validation should be created for radiographic images.” In fact, Participating dentists were only correct in identifying the manipulated image in 56% of cases, 6% higher than by chance.”
An article over two decades old (1999) in the Journal of the American Dental Association alerted the profession to the ease in manipulation of digital images for nefarious purposes. The researchers artificially added large restorations, dental caries, fractures, and periapical pathosis to the x-ray images.
Then the images were forwarded to insurance companies for prior treatment authorization.
The results were as follows: “In each case, the insurance companies authorized the proposed treatment based on the appearance of the teeth on the radiographs. The altered images illustrated an apparent need for dental treatment that was not required and that could have led to payment for treatment that was not actually performed.”
ORIGINAL X-RAY INTEGRITY ONLY PROTECTED AT SOURCE DATABASE
Joerg Haist, Head of Diagnostics Platform, Product Marketing & Development at Dentsply Sirona offered the following interview for Dentistry Today:
“Basically, all digital dental x-ray images are saved as original in the database. If users make changes, e.g., contrast, brightness, filters etc., the changes are saved in a ‘session,’ but the original remains unaffected.”
“The actual image files are managed in a ‘hidden’ background. This measure serves to avoid accidental or intentional manipulations. Therefore, the DICOM file format is used, which enables a clearer definition than standard file formats, e.g., the fixed assignment of an exposure to a patient.”
Haist continued, “In order to protect against malicious changes to the digital dental x-ray images, the general principles of cyber security apply (e.g., use of firewall and virus scanner) as described in our (cyber) security white paper.”
“With the latest software updates, measures against unauthorized access to data have been improved, e.g., clearly secured interfaces are introduced, which require encryption and authentication of the communication partners.”
Haist concluded, “If a recording (image) is exported and passed on outside the protected network, the recording is of course no longer subject to this protection. But this is only a copy, the original is still protected in the database.”
SOLUTIONS
Anti-tampering techniques and methods for detecting manipulations in digital medical/dental images are imperative. Cryptography techniques inclusive of digital signatures and watermarking might alert to possible nefarious or inadvertent manipulations of digital medical/dental images.
Manufacturers will only be motivated to incorporate anti-tampering safeguards if motivated by demand of industry consumers or mandated by legislation.
Until or unless such safeguards on copies of digital images are standard, the only 100% validated copy will be one sourced directly from the original computer database. This is critical information for insurance industry reviewers, professional peer-review, state dental boards, legal experts in review of civil and criminal lawsuits, and TPAs administering Medicaid claims.
As the old Russian proverb goes, “Trust but verify.”
DEDICATION
In memory of Dr. Robert Glenn Williams, who passed July 1, 2022. Dr. Williams served in Dallas, Texas, as Chief Forensic Odontologist for the Southwestern Institute of Forensic Sciences. He consulted with the Texas Attorney General’s Office and US District Attorney’s Office.
In pursuit of truth, Dr. Williams traveled some uncomfortable and dark paths, which served to enlightened us all.
ABOUT THE AUTHOR
Dr. Michael W. Davis practices general dentistry in Santa Fe, NM. He also provides attorney clients with legal expert witness work and consultation. Davis also currently chairs the Santa Fe District Dental Society Peer Review Committee. He can be reached at MWDavisDDS@Comcast.net.
FEATURED IMAGE CREDIT: Quang Tri NGUYEN on Unsplash.
