How to combat illegal and unethical dental insurance practices
Step one is to document if you see a recurring issue. Second step is call your state’s insurance commissioner to file a compliant. Third is contact your local, state, and national dental society. Fourth is contact a professional, like the ones listed below. You will need to be persistent for any changes to actually occur. The tip on page 14 of February 2017 dental economics by Ben Tuinei sounds good.
“Just like the speculators who witnessed the fleet of shells exploding at Fort McHenry, both Tessina and I felt defeated. But that sense of discouragement lasted only minutes as Tessina then picked up the phone and contacted our state insurance commissioner to file a complaint. Her first try with the commissioner was not a success. “Not enough doctors are complaining about this same issue,” was his office’s reply. With her relentless attitude, Tessina called the insurance commissioner a second time and reported that she was organizing a meeting of 200 local office managers who would agree to file similar complaints against the same insurance carrier. Knowing how much of a workload this would create, the commissioner’s office pleaded with Tessina not to encourage 200 other offices to file similar complaints. Instead, the commissioner agreed to take on Tessina’s complaints only.”
How to negotiate reimbursement rates.
I never realized this profession existed! I am not in network, but if I was I would hire these guys or someone like them ASAP!!
Apex reimbursement specialists Harold Gornbein from DE article PPO negotiation costs $7,000, UCR fee schedule analysis is $185 and a coding analysis is $1,500.
Dental Insurance issues that a dentist cares about
Collection of dental insurance issues I have seen come up and see asked again and again.
Is it legal to waive co-pays?
You can waive the co-pay but you need to notify the carrier. Delta considers, emphasis on Delta considers, it fraud if do not notify the carrier that you do not attempt to collect co-pay. However, if you are in network it is likely against your contract so there would probably be some contractual issue. If the contract is silent on the issue then a waiver is permissible according to CDA.
Out of network
Do not advertise that you waive co-pays. Jason Wood’s opinion seems to be that OON can do what they want. Probably best practice to just put it in the remarks section or not do it at all. It appears that these two legal cases the OON side won, legally speaking.
Chris with ISDS says the Feds would consider ant fee not charged or waived to be unfair business practice. That consistency would be important in that as well. The Office of Inspector General can investigate anything they want at any time. So technically everyone should be charged same fee at all times no matter what. That means no senior citizen discount or professional courtesy to other doctors. This doesn’t sound right to me but may be technically accurate. He did say that he is not aware of any practice ever having an issue with this though.
Insurance company asking for a refund.
We feel that we have been properly reimbursed for services rendered. Please do not hesitate to call me if you have any questions or need additional information. You can contact me at xxx-xxx-xxxx.
Insurance company trying to cap non-covered procedures is illegal in many states.
Pdf file that shows the state laws protecting patients and practitioners from insurance companies trying to cap non-covered procedures.
Dental insurance denying a procedure
Don’t mess around with them. Go straight to your state’s insurance commission and have the patient go to their HR department. Other tips, such as responding to rejections, are found on the ADA website and the ADA will help if you are an ADA member. You can call the ADA’s third party payer concierge at 1-800-621-8099 or email at [email protected]