INSURANCE CONNECTION
Insurance Questions and Answers
Q : I began work on a patient , submitted it to the insurance carrier and received payment . But the patient refused to let me complete the work . Is there an issue ? A : Probably . If you submit a claim for payment for service not actually completed , there may be question of insurance fraud . Submit claims for payment only after services have been rendered .
Q : Is an insurance carrier obligated to send an Explanation of Benefits ( EOB )?
A : Although most insurance carriers issue EOBs , they are not required to do so . However , they are required to maintain a record of services and to have such record available .
Q : What can the American Dental Association ( ADA ), the Pennsylvania Dental Association ( PDA ) or my local dental society do to stop insurance carriers from getting a foothold in my area ?
A : Organized dentistry does not typically try to stop insurance carriers – indeed , to do so could create substantial anti-trust risk for the association and those involved . Whether and how to participate or cooperate with an insurer is an individual decision that each dentist must make . The associations offer a wealth of information to help members make a decision .
Q : Can I consult with other dentists to establish fees ?
A : Anti-trust laws view dentists as competitors in the market and view agreements between competitors to fix prices as presumptively illegal . Therefore , discussions among dentists to establish fees may expose dentists to allegations of price fixing , per se .
Q : What factors should I consider with respect to participation with an insurer ? A : Dentists are asked to participate with an insurance carrier and to provide services to Insurer ’ s members , usually at a reduced allowance . In exchange , the insurance carrier lists the dentist ’ s name as a participant , ostensibly to attract the insurer ’ s members into participating practices . As a participant , dentists are obligated to accept the insurer ’ s allowance as paid-in-full , less co-insurance and deductible . Among the factors to consider with respect to participation are the following :
• What is your personal philosophy ?
• How will fees be impacted ?
• Will the anticipated increase in patient load offset the fee reductions ?
• Do many businesses in the area offer dental insurance ?
• Do other dentists in the area participate ?
• Does the insurer offer “ Assignment of Benefits ” wherein the patient can direct the Insurer to send the check directly to the dentist , irrespective of participation ? ( Note that the PDA is currently lobbying for a law that would obligate Insurers to recognize “ Assignment of Benefits ”.)
• Since fees will likely be reduced , what percentage of the practice can sustain the decreased fees and allow for a reasonable profit .
• What does the insurer expect of me ?
• What are the Utilization Review requirements ?
• Will insurance representatives be permitted to conduct audits ?
• Is there a Credentialing process ? If so , what is it ?
• What is the terminal provision of the contract ?
Please be advised that a PDA member dentist can ask for an analysis of an insurance carrier ’ s participation agreement . Simply e-mail a copy of the agreement to vjp @ padental . org and the PDA will coordinate the review with the ADA .
Q : Can a participating dentist bill his / her full fee for non-covered services ?
A : Yes and No . Pennsylvania legislators passed SB1144 which became effective Dec 25 , 2012 . SB1144 is a compromise bill between organized dentistry and Insurers . This bill provides for an option for
participating dentists to accept Insurers ’ fees for non-covered services as follows :
• If the service is completely non-covered under the terms of the Insured ’ s agreement , the dentist may bill his / her full fee .
• However , dentists are obligated to the Insurers ’ allowances if the service is not covered because : o Deductible has not been satisfied o Co-insurance is applicable o Patient reached a lifetime or annual maximum o Service is limited by frequency o Payment was made for an alternate form of treatment Please refer to the May / June 2013 issue of the Pennsylvania Dental Journal or contact vjp @ padental . org for additional information concerning SB 1144 .
Q : Can a dentist limit the number of Medical Assistance ( MA ) patients in their practice ?
A : Pennsylvania ’ s state MA statute permits providers to choose or limit who they serve , as long as they only do so fairly and on a non-discriminatory basis ; i . e ., that a provider does not discriminate based on any factors prohibited under Civil Rights laws , and applies their policy equally and fairly to all patients served regardless of whether they are MA recipients , covered under commercial insurance , self-pay , etc . The Department does not exercise jurisdiction over Civil Rights laws and cannot approve or guarantee that any arrangement a provider enters into will be free from discrimination challenges / allegations , or that the provider will prevail if challenged . We strongly recommend that providers opting to apply such policies post the policies in an open and conspicuous manner ( such as the waiting room ), and inform all of their patients of the policies in advance .
( Source : PA Department of Public Welfare )
S E P T / O C T 2 0 1 3 | P E N N S Y LVA N I A D E N TA L J O U R N A L 4 1