This article was originally published in the CDHA’s Oh Canada, Fall Issue, 2025
by Amanda Acker, HBScDH, RDH; info@polishedinsights.com
INTRODUCTION
Billing practices in privatised health care can profoundly impact the patient experience, system efficiency, and professional autonomy. Within the Canadian dental hygiene sector, examining billing transparency has become increasingly important. Advancing provincial scopes of practice, combined with the imminent inclusion of millions of individuals under the Canadian Dental Care Plan, is colliding with inconsistent billing standards, creating confusion, ethical risks, and financial risk of harm.1 Furthermore, the growing privatisation of health care in Canada makes billing transparency and standardisation increasingly important as Canadians navigate this increasingly complex system.2-4
In Canada, the profession of dental hygiene, like other regulated health professions, operates within regulatory frameworks designed to prioritize the public interest by reducing the risk of harm to clients. The inclusion of financial elements in these frameworks varies significantly across the country, leading to inconsistencies, ambiguous standards, financial risk of harm to clients, and ethical dilemmas for dental hygienists navigating these complexities without clear guidance.5,6 In addition, despite fully autonomous practice, dental hygienists are allowed by provincial regulators to bill under another provider’s unique identification number (UIN), which is an ongoing legacy practice that undermines transparency, compromises professional autonomy, and potentially erodes client trust. It is also in direct breach of established billing recommendations from insurance industry stakeholders.7-9 Interestingly, no other regulated health profession in Canada is permitted to perpetuate this legacy practice, as it undermines the client’s transparent claims experience.
This essay explores how regulatory and other institutional factors influence the billing practices of dental hygienists in Canada and proposes recommendations designed to enhance clarity, mitigate financial risk for patients, and promote consistent, ethical practices nationwide.
BACKGROUND
Although current provincial standards of practice and codes of ethics for dental hygienists in Canada include common principles such as client autonomy, non-maleficence, beneficence, and jurisprudence, there remains substantial variability and inconsistencies in regulatory guidance on billing practices.6 The professional standards across the provinces remain inconsistent or inadequate, evidenced by a lack of specific guidance that adequately addresses the intricacies of coding, billing, and claims management. The consequences of these gaps create ambiguity and may result in financial harm to the client.3,4
This research supports the need for a comprehensive analysis of existing regulatory structures and systems relevant to the financial aspects of practice. Clear and standardised billing practices support informed decision making and consent for the client and subsequently help protect them from financial harm.3 Upholding consumer rights through transparent billing practices aligns with the ethical standards that are expected in the provision of dental hygiene care.
INSTITUTIONAL FACTORS
a) Political: Regulation
Some provinces in Canada explicitly outline financial consumer protection in their dental hygiene regulatory frameworks, whereas others have not.6,10 Minimal, if not absent, guidelines on this topic have created gaps in protecting patients from potential financial harm associated with dental hygiene billing practices.
In Canada, dental hygienists increasingly possess full practice autonomy, whereby no oversight, direction or supervision is required by another provider to perform their full scope of practice.6 However, the ability to bill under another provider’s UIN hinges on the elements of supervision by another provider. Despite their professional autonomy, some dental hygienists continue to use another provider’s UIN for billing, primarily due to legacy practices or administrative convenience, which raises ethical concerns. Indeed, the pervasive practice of dental hygienists utilising another provider’s UIN may compromise professional autonomy, confuse accountability, and prevent transparency, which in turn adversely impact both patient trust and professional credibility.8,9,12
Through standardised recommendations aimed at calibrating dental hygiene regulatory practices nationwide, inconsistencies could be mitigated, client vulnerability reduced, and consumer confidence in dental hygiene services enhanced.4.5,7
b) Organizational: Capacity Building and Professional Autonomy
Professional autonomy and its positive correlation to access to care have long been understood among regulated health professions.14 In the broader health care field, specifically in the nurse practitioner profession, initial research has demonstrated the positive effects of improving billing compliance by empowering mid-level primary health care providers in the use of their own UINs.11,14 Research also supports that this contributes to clearer patient‒provider interactions and enables the provider to work to their full scope of practice.11 Autonomous practice in nursing has also been associated with higher status within health care delivery systems, expanded scope of practice, improved billing practices, and reduced provider workforce gaps.14
These findings may be generalizable to oral health care networks as they are characterized by a highly specialised division of labour, with pronounced professional and workplace hierarchies. Strengthening provider autonomy and agency significantly informs policy decisions and professional practices, ultimately driving systemic improvements in the quality of patient care, accessibility, and workforce sustainability.
c) Economic: Insurance Industry
The economic implications of fraudulent billing practices within Canada’s health care system are severe, as fraudulent dental claims alone cost hundreds of millions of dollars annually.15 Such fraud affects insurance premiums and creates barriers to care for many individuals, particularly vulnerable populations.9,18,19 Implementing measures to reduce fraud and ensure a transparent and understandable claims process for consumers is vital. In Canada, consumers have the right to a timely and transparent claims experience.18 Despite fully autonomous practice capabilities, dental hygienists in many provinces are allowed to bill under another provider’s UIN, undermining transparency and patient rights.7 Understanding the structural factors facilitating fraud, particularly within dental hygiene billing, is vital for devising effective countermeasures.
Examining existing billing practices, identifying refinements to enhance transparency and mitigate fraud risks, and addressing structural vulnerabilities are essential to creating an equitable and trustworthy claims environment for both consumers and providers.
d) Social: Education and Power Dynamics
The positive impact of formal education on health care billing practices has long been understood.21-23 In the medical field, a growing body of evidence suggests incorrect billing may not always be fraudulent or corrupt, but rather the outcome of medical practitioners who struggle to interpret and navigate increasingly complex legal requirements. Such confusion surrounding health financing and billing transactions may be improved through education.21 In Canada, very few financial and no explicit billing competencies are included in the entry-to-practice competencies for dental hygienists.24 This raises concerns about whether educational needs are being met in this regard for dental hygienists.
Finally, although workplace power dynamics have emerged as a recurring influence on billing practices within the nursing profession, research pertinent to oral health care and dental hygiene remains limited.12,25,26 Yet, as with nurses, dental hygienists face real challenges within hierarchical dental office environments – a situation that led six in ten to reveal in a national survey that they had experienced bullying, harassment, abuse and violence in the workplace.27 Considering the persistent misalignment of billing practices with the scope of practice, these social institutional factors warrant investigation as the real-world tensions created by power dynamics cannot be overlooked as a potential contributor to the perpetuation of billing practices in Canada.
RECOMENDATIONS
By examining the complexities of billing practices, this essay aims to empower dental hygienists with a better understanding of their roles and rights within the professional landscape. To address the regulatory, ethical, and institutional inconsistencies in billing practices of dental hygienists in Canada the following recommendations are proposed:
- Include billing practices in provincial standards of practice across Canada. Regulators, in collaboration with other stakeholders, should clearly define appropriate billing practices, including the use of UINs, to align with the realities of autonomous practice in their respective provinces. This should not be confused with either business ownership or independent practice. The language used in these guidelines should explicitly outline the client’s financial rights and protections. This information should also be included in public-facing documents to reinforce consumer trust and informed consent.
- Mandate, in provinces where scope of practice allows, the use of UINs for all practising dental hygienists. This change would modernise the billing practices of dental hygienists and ensure that ethical standards are met and consumer rights are upheld through transparency and standardisation.
- Integrate elements of billing and financial ethics into entry-to-practice competencies, ensuring that the educational needs of dental hygienists are met to support fraud prevention and ethical financial conduct.
- Address workplace power dynamics through ongoing research and lobbying. Provincial and national associations play a crucial role in identifying and supporting members as they navigate workplace power dynamics that may perpetuate archaic billing practices.
- Improve stakeholder collaboration and data collection. The sharing of anonymized billing data among insurers, regulators, and associations would further inform areas for improvement. Greater data transparency will support evidence-informed policy decisions and reforms.
By implementing these recommendations, regulatory coherence can be strengthened and professional accountability reinforced, thereby building toward a more equitable and transparent oral health care landscape in Canada.
CONCLUSION
This essay highlights the need for consistent and comprehensive regulatory frameworks governing dental hygienists’ billing practices in Canada. This research ultimately supports the need to improve the identification and articulation of financial best practices and client protections, and to promote equitable access to dental hygiene services in Canada.
REFERENCES
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