Dental Patients Face Years Of Debt, Inflated Bills

By Manuela Tobias, The Fresno Bee

Kenda Williams, 51, went to West Coast Dental in Torrance to treat the shooting pain in her molar. She spent the day in a drug-induced haze.

Williams later found out she had signed up for two credit cards that day to cover her dentist’s $9,055 bill. Unemployed and on Medi-Cal, the Los Angeles resident had no idea why her bill was so high, or why she had been approved for so much credit.

“I thought I was just getting a root canal,” Williams said. “They were giving me a bridge. I already had a denture that was brand new. They’re claiming I asked for a bridge and I did not. They knew I could not afford it because I was unemployed. All I went in for was a root canal.”

She does not recall signing up for the cards, and she said the signatures on the consent forms do not match her own. 

The dental office did not send in an authorization form to her insurance provider, a Medi-Cal managed care plan, documents show. The insurance company later reimbursed her for $1,070 worth of services, but she still owes about $6,000.

“I have a couple clients that I clean their houses twice a month and that’s been helping me make these payments,” Williams said. “It’s really sad. My husband, he’s older, he can’t find work. And it’s just been really hard and we’re gonna have to sell our house. Family and friends help us when we need it. But it’s been hard.”

Across California, patients like Williams are wading into years of debt because of high-interest credit cards used to finance dental treatment. They have succumbed to requests by dentists to put their high-priced services on a controversial segment of the health care industry: companies that offer loans for “out-of-pocket” medical care.

An investigation by The Fresno Bee for The California Divide, a statewide media project examining economic inequality, has found that some dentists appear to be inflating bills and pressuring patients to put their services on a credit card.

These credit contracts, which can be easily arranged in the dentist’s office, often have deferred interest provisions, which means that if the patient does not pay in full within a certain time period, interest on the initial loan is charged, with rates ranging from 13% to 29%. 

The Bee also found that some dentists charged for care in full before services were performed, leaving patients like Williams paying their bill without ever having their treatment completed.

Legal aid organizations report that low-income Californians are particularly at risk of falling into debt traps with medical credit cards because of ongoing struggles with the state insurance system. Medi-Cal doesn’t cover major dental care unless it is medically necessary, and a limited number of Medi-Cal and Medicare providers render the full range of covered services.

“We definitely see dentists refusing to run the (Medi-Cal authorization) request a lot,” said Eric Schattl, supervising attorney at the Neighborhood Legal Services of Los Angeles County. “So then they’re guiding people toward the card early on in the process, even if they know they are Medi-Cal recipients. Even if the paperwork may say, ‘this is a covered benefit.’ ”

West Coast Dental in Torrance declined to comment about Williams’ case.

But advocates say the terms of medical credit cards are too complicated for most people to understand. They are particularly confusing in high-pressure situations, like the moments of excruciating pain leading up to important dental procedures.

“It’s a dentist pitching this product. Your relationship with the dentist is a very intimate relationship. You have to trust the dentist — they’re in your mouth,” Schattl said.

Millions of accounts

Nationwide, more than 6 million accounts are active with CareCredit, a product of Synchrony Bank. It is the most popular medical credit card on the market, according to the U.S. Government Accountability Office. The card can be used to finance anything from veterinary services to LASIK eye surgery. It is offered at 109,000 dental offices nationwide.

There’s no way to know how many cardholders have encountered problems like Williams endured. Consumers often don’t know where to file grievances, and the California Dental Board is not required to disclose any information on complaints.

Of the thousands of consumers who filed complaints against Synchrony Bank nationwide in the last five years, 177 consumers, including 43 Californians, mentioned the word dentist or dental. There could be hundreds more, however, as most people opted not to publish their complaint narratives.

The Health Consumer Alliance, a statewide coalition of legal service offices, says it has reviewed and helped consumers on 28 dental credit card cases so far this year, and 55 cases in 2018. Central California Legal Services, based in Fresno, estimates they reviewed 24 cases since 2013. 

“It does not sound like a large number, but the cases are egregious, and we get a tiny fraction of people having an issue,” said Joy Dockter, an attorney and health advocate at Central California Legal Services.

Medical credit cards are not all that different from other credit cards on the market. But customers don’t need to go to a bank to take them out; health care providers can fill out a client’s application and have it approved in seconds. 

“The reason that they are popular is that they’re marketed in a way that oversimplifies in an almost misleading way what the person is obligated to. It will say zero percent financing,” said Gina Calabrese, a professor of legal clinical education at St. John’s University Calabrese. “Most financing agreements are written in a way the average person can’t really comprehend.”

Beginning next July, a new state law will prohibit health care providers from signing up patients for deferred interest credit products in their offices. The credit industry and dentists had worked to water down the bill; the original version would have prohibited providers from offering or promoting such products.

Lisa Lansperry, a spokeswoman for CareCredit, said an internal survey showed 94% of their customers were satisfied in 2018. She added that if a consumer has a complaint, the company takes it seriously.

Although CareCredit processes thousands of deferred interest transactions a month in California, it receives on average one complaint a month from Californians through CFPB, Lansperry said. She added that only one of every five customers using deferred interest products pay interest on their loans.

The California Dental Association, which represents over 27,000 dentists, endorses the cards because many people lack adequate insurance to cover the dental treatment they urgently need, according to spokeswoman Joie Harrison.

CareCredit has 120 partnerships, over 70 of which are paid, with industry groups, including the California Dental Association. CareCredit paid providers a total of $12 million in 2018 to promote its products. Both CareCredit and the California Dental Association declined to disclose whether the dental association was paid for promoting credit cards to patients.

Across the United States there are more than 6 million active CareCredit accounts.Daniel Kim/The Sacramento Bee

The appeal for dentists is clear. Minus merchant credit card fees, their immediate payment is guaranteed, and gone is the administrative burden of holding a patient to account.

“In a private office we don’t want to chase down payments,” said Dr. Mark Cave, the dental director of Fresno’s Clinica Sierra Vista, who also has a private practice in Visalia. “If we have to hound you for $25 we lose relationships over that with patients. You owe me $300 but you’re sending me $25, and I’ve got bills to pay, too, or we can go to CareCredit.”

Cave, like other dentists The Bee spoke with, said he makes sure the patient understands the full terms of deferred interest before facilitating the loan.

‘I didn’t have any teeth left’

A 57-year-old agricultural worker in Selma, who did not want to be named because she feared retaliation by her dentist, had a similarly nightmarish experience.

She went to her Fresno dentist, which she found on a list of providers who accept Medi-Cal, to fix a deteriorating seven-year-old crown on her top teeth last July. The metal peeking through her front tooth was embarrassing, and the hole in a back tooth was uncomfortable.

Her dentist insisted she needed a bridge replaced and urged her to take out $10,000 in credit to pay for it. That bill is equivalent to nearly one year of her work as a seasonal, minimum-wage worker at a fruit-packing shed. She signed up for the loan and the dentist went to work.

As she left the office with an uncomfortably large temporary bridge, she learned she had only one year to pay her debt before 27% back interest on the loan kicked in. She said the dentist did not send in authorization requests to Medi-Cal for her treatment.

Within two weeks, her dental work fell apart. It was painful to eat, talk or show her face. She said she used putty from Wal-Mart to fill in the gaps in her teeth.

“I was left without any teeth,” the woman said in Spanish. “From everything they did to me. I covered my mouth because I didn’t have any teeth left. I didn’t have anything left.”

She refused to have the work completed and complained to the credit card company, which canceled her account. But her dentist continues to hound her over payment.

The New York Attorney General and the Consumer Financial Protection Bureau cracked down on CareCredit in 2013 for deceptive enrollment practices. Clients were not receiving clear communication about deferred interest or copies of their card agreements. Poorly trained staff at some providers’ offices were confused about the product they offered. CFPB created a $34.1 million reimbursement fund for more than 1.2 million clients.

As a result, CareCredit now prohibits credit over $1,000 from being taken out the day medical work is done. But the Bee found multiple dentists do it despite this prohibition. The company relies on patients to self-report violations.

Western Dental, the largest dental chain in California, says on its website that CareCredit offers zero percent financing. There is no mention of the 27% interest rate that kicks in after six to 24 months.

Western Dental spokesman Bill Halldin said he appreciated that The Bee raised this concern, and would work with CareCredit to update the language. (It has not yet been updated.) He said those terms were laid out on the CareCredit website.

Michael Hoopingarner, a film producer in Los Angeles, was fresh out of college in Chico, California, when he used CareCredit in 2009 to finance a dental treatment.

“At the time, I thought I understood the rules. I think it was advertised as zero percent interest for one year. What they didn’t say was that if you crossed the one year mark, not only will you begin to be charged interest, but you’ll be charged back interest.”

Hoopingarner was left with a bill of more than $500 he could not pay, he recalls, because he misjudged the payment date and missed the cutoff to pay off his balance.

In complaint after complaint on various rating websites, CareCredit has been criticized by customers for many of the same reasons. Although the Bee could not confirm every story, it’s clear that the company has struck a nerve with thousands of customers. 

Complaints to CFPB about CareCredit range from a woman in Sun City who received a bill for nearly $1,000 in deferred interest on top of her $2,679 loan for shoddy dental work, to a customer in Orange County who was hounded over payments for two years for crowns they never received. An elder person in Los Angeles County reported their balance shot from $1,000 to $1,400 unexpectedly.

“Nobody at my dentist’s office ever told me when I signed up for CareCredit that the rate would suddenly increase from 0% to 26.99% or that the interest would accrue during a promotional period,” they wrote. “Nobody even gave me a copy of the credit card agreement.”

In Temecula, a woman was urged to take out credit worth $2,679 for a bridge over three front teeth. The bridge did not fit properly, and food got stuck in the hole left behind the bridge, resulting in multiple infections. The dentist refused to fix her teeth, she reported the issue to CareCredit and was told no interest would be charged. Still, she was nailed with a bill for $966.56 in deferred interest on top of her loan, and she says she is too embarrassed to smile.

Whether it was for credit card fraud, shoddy treatment or unexpected interest, most of the customers who filed complaints with CFPB reported spending significant time on the phone with customer service to no avail. Complainants requested the company cancel their accounts, but no one addressed the issue for months. In some cases, their credit was ruined because they either refused to pay their balance or were instructed to do so by the company.

Legislative reforms

State law passed in 2009 already requires that dentists disclose to patients they are signing up for credit with a third party, and charge only services that have been provided. In 2014, that law was amended to cover all providers, not just dentists.

These incidents continue to happen because the onus lies on the consumer according to Jen Flory, a policy advocate at the Western Center on Law and Poverty, which sponsored the original law.

“A violation is a violation of the consumer legal remedies act. It gives them the right to sue and the right to certain penalties,” Flory said. “But it is very difficult for people to find attorneys for low dollar amounts. It’s generally preferable to deal with before going to court.”

Jen Flory is a policy advocate at the Western Center on Law and Poverty, which sponsored a bill that prohibits health care providers from signing up patients for deferred interest credit products in their offices.Daniel Kim/The Sacramento Bee

Flory said that with the proliferation of medical credit cards, and the popularity of deferred interest products, the situation has worsened. So in the 2019 legislative session, the organization sponsored a bill authored by Sen. Holly Mitchell, D-LA, that would prevent deferred interest credit products from being offered or even taken at health care providers’ offices. But lobbyists watered down the bill significantly.

“We got a lot of pushback that people love deferred interest, at least the people who can afford to pay off the entire balance before the interest kicks in, and we just didn’t have the votes to push that forward. If we can’t stop these products, at least we can make sure people are aware they are signing up for a third party product and have a little more trepidation when signing up for that.”

The amended bill, signed into law on Oct. 12, prohibits providers from signing people up for credit in-house. They can still promote materials so that patients sign up for credit on their own, and accept deferred interest credit products for payment. The law also states that services must be rendered within 30 days of payment.

“My point is not to eliminate (credit) as an option,” Mitchell said. “I want people to have products they need to survive. I don’t want them to have products that aren’t clearly articulated in terms of the details. They also understand that I’m not pointing the finger at dentists as the bad guys.”

‘That can end really badly’

Applying for a card on her own didn’t do much to help Marilyn Braun, an 84-year-old woman from Palm Desert.

Braun had applied for credit online for the five crowns she had done in March at Parc Center Dental Group in Palm Desert. She was paying $205 a month, or over a fifth of her Social Security check each month. She had 18 months to pay back her $3,675 loan before a 27% deferred interest rate would kick in.

In July, Braun had to choose between paying her electricity bill or her dental bill. She chose CareCredit, because the late fee can reach $39.

Braun said she presented her dual Medi-Cal-Medicare card to the dentist’s office manager in March before treatment, which covers some crowns. But she said the office told her they do not accept her insurance, and encouraged her to finance the crowns through CareCredit instead.

After the Bee called Dr. Kourosh Dianat’s office to corroborate, Dianat said they do accept Braun’s plan, but she had simply not shown her card. He said she only showed her California Network card, which affords some discounts. She has now been fully reimbursed.

“We didn’t know she had another plan,” Dianat said. “If she had just done the regular fees which was covered by the California Network, the total amount would have been $2,625 but since she wanted to upgrade to a porcelain crown, it came to $3,675. Those are the things she chose. She signed the consent forms and signed up for CareCredit herself.”

Like Braun, many of the patients that resort to legal aid services blame themselves for falling into these debt traps so they don’t file complaints.

“People are embarrassed that they’ve gotten themselves in this situation,” said Gerrie Schipske, an attorney at the Health Consumer Action Center of Community Legal Aid in Southern California, who reviewed four dental credit card cases this year. 

“They feel like, ‘How dumb was I? I did this. I should’ve known better.’ They’re being unfairly taken advantage of.”

Ted Rossman, industry analyst at CreditCards.com, advises consumers to stay away from deferred interest plans, regardless of where they sign up for them.

“I’m really suspicious of this idea you can be charged retroactive interest if you can’t make all the payments before the clock runs out,” Rossman said. “That can end really badly.”

Manuela Tobias is a journalist at The Fresno Bee. This article is part of The California Divide, a collaboration among newsrooms examining income inequity and economic survival in California.