Dealing with dental insurance

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!!

Veritas Dental Resources

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?

Well that depends. Never for government programs like Medicaid. My opinion is that it legal as long as you follow some of the rules. Here is a great dentaltown thread on the exact same question.

In network

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.

 

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 are in receipt of a refund request in the amounts of:
We have reviewed these account thoroughly, and according to our records, the claim has been paid and the account is closed. You will be pleased to know we find no balance due from your company, nor do we find any payment that you are entitled to recoup. We have applied all appropriate contractual adjustments, if they apply, and the patient has been balanced billed for their responsibility, if any.
According to federal law, as a third party creditor, we cannot be held liable for mistakes on the insurer’s part. We obtained the patient insurance information at the time of service and there was every indication we were entitled to 3rd party payment from your company, based on the patient’s representation.
If you are claiming an overpayment, we received your payment and your Explanation(s) of Benefits dated xx/xx/xxxx, <copies enclosed> in good faith. Based on your payment and Explanation of Benefits, we did not bill the patient for the portion covered by the insurance. We have provided services in good faith, and the funds received have been exhausted.
There are several court decisions that bear on this situation. In 1992, the California Court of Appeals held that, if a provider bills in good faith, and the insurance company accidentally pays too much based on the insurance company’s own calculation, the company cannot collect a refund from the provider, so long as there was no misrepresentation or fraud on the provider’s part in billing (City of Hope Medical Center v. Superior Court of Los Angeles County (1992) 8 Cal.App.4th 633). The discharge for value rule, or the innocent-third-party-creditor rule, has also been applied in an analogous situation. Numerous courts have held that an insurer is not entitled to recover payments erroneously made to an insured’s health care provider. See National Benefit Adm’rs, Inc. v. Mississippi Methodist Hosp. & Rehabilitation Ctr., Inc., 748 F. Supp. 459, 464-65 (S.D. Miss. 1990). See also Time Ins. Co. v. Fulton-DeKalb Hosp. Auth., 438 S.E.2d 149, 152 (Ga. Ct. App. 1993); St. Mary’s Med. Ctr., Inc. v. United Farm Bureau Family Life Ins. Co., 624 N.E.2d 939 (Ind. Ct. App. 1993); Lincoln Nat. Life Ins. Co. v. Brown Schs., Inc., 757 S.W.2d 411 (Tex. Ct. App. 1988).
Similarly, your company, as the insurer, made a payment to discharge a debt owed by the patient, and we are not required to refund the payment based on your calculations and which we received in good faith.

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.

 

Legislation state by state both online link and pdf in case disappears dealing with how an insurance company can ask for a refund.

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.

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