III. How to Resolve Conflicts
Opening or building a dental practice is a difficult and laborious activity, and the process rarely becomes easier. As with others starting a business, the dental health care provider is required to fulfill a variety of roles, with each one having unique interests and priorities. Your responsibilities as an employer differ from your requirements as a small business owner and operator, which differ from your responsibilities as an involved citizen within your community, and so on. You are also a health care professional whose goal is to provide quality treatment to each patient and to build a successful practice.
As you juggle the various responsibilities inherent in each of these roles, your patients may also call upon you to serve as the intermediary with their employer or insurance carrier in order to ensure that they receive the maximum benefits allowed under their dental insurance plans, while they contribute the lowest rate of co-payment possible. For many practitioners and their employees, this role produces the most stress and requires the most time. In fact, previous membership surveys have shown that members want the AGD to be actively involved in solving problems with third-party payment mechanisms. While there is no “quick fix” approach to resolving conflicts with third-party carriers, this chapter may help to reduce the frequency of these situations. On the following pages are descriptions of problems common to third-parties and sample draft responses to assist you in resolving these situations. You may also want to refer to Chapter 4, which lists relevant AGD policies and to Chapter 6, which contains additional information from the AGD’s Membership Survey and fact sheets to assist you in educating patients and resolving problems with carriers.
AGD Headquarters has often successfully intervened on members’ behalf to resolve a variety of problems with third-party carriers. Successes include persuading an insurance company to change its policy and allow dentists to prescribe nicotine patches and persuading a self-funded plan to change its policy to allow general dentists to perform services that were previously identified as a specialty area.
The AGD also played a key role in changing the placement of a fraud warning on one carrier’s Explanation of Benefits statement. A few years ago, the California State Society of Orthodontists announced a media campaign that would result in consumers bypassing general dentists as primary oral caregivers. Their consumer kit instructed parents on how to take impressions to determine whether their children needed orthodontic exams. After speaking with the AGD, their campaign was altered to encourage consumers to seek services from general practitioners as well as orthodontists. Most recently, the AGD and other organizations successfully compelled a clear aligner company to remove its onerous minimum patient quota requirement for use of its product.
Make sure to keep AGD Headquarters informed of situations with third-parties. They are always interested in learning about constituent success stories, and can provide guidance and other assistance.
Be aware that the conflict resolution approaches suggested in this chapter may not always be successful, particularly in cases involving self-funded insurance programs. In this dental benefits model, rather than purchasing coverage from an insurance carrier, the employer or sponsoring entity assumes the role of insuring agency and incurs the financial risk of the program. Often an insurance carrier or third-party administrator may be retained to process claims and perform other administrative functions.
Self-funded plans are regulated by the Employee Retirement and Income Security Act (ERISA) and are exempt from state regulations. As a result, the individual State Boards of Insurance can’t act on complaints against either a third-party administrator or the company offering the self-funded plan to its employees. In addition, some insurance companies that offer traditional insurance also serve as third-party administrators for self-funded plans. This sometimes causes confusion in determining where to refer a patient for investigation of a complaint. When in doubt, contact the claim office to determine if the plan is self-funded or if it is a group insurance policy. When a problem arises under a self-funded plan, the U.S. Department of Labor is the appropriate authority for investigating the patient’s written complaint.
It is important to be aware that ERISA does not specify time limits for the payment of claims, but reasonably prompt payment is expected. In those cases where a self-funded program habitually delays payment for an unreasonable amount of time, you may receive payments more promptly by sending a letter of complaint to the employer or the third-party administrator.
AGD Checklist for Resolving Problems with Carriers:
Before consulting the suggested steps to resolve any particular situation, we suggest you review the AGD Checklist for Resolving Problems with Carriers, which appears on the next two pages. We also encourage you to communicate these guidelines to your membership by printing them in your constituent newsletter or by distributing them in response to member requests for assistance in resolving third-party conflicts.
The Checklist was developed by the Dental Practice Council as a way to help individual members resolve third-party problems. Council members believe that it is best to handle most situations locally by having the dentist’s office staff work directly with the carrier. The Checklist calls for the dentist’s office staff to build a cooperative relationship with local carriers. A good working relationship can solve many problems, and the closer the practitioner and staff are to the carrier, the more effective they can be at resolving any difficulties.
The Council also suggests involving the patient in the resolution process. The individual patient is most impacted by the carrier’s policies—he or she needs and wants the dental treatment and is ultimately responsible for payment. Also, the carrier is more likely to listen to the patient’s complaint about the policies of the dental plan than to respond to the objections of an outside party.
AGD CHECKLIST FOR
RESOLVING PROBLEMS WITH CARRIERS
Type of Insurance:
___ Fee-for-Service (indemnity)
I Specifically, what is the problem, what is your complaint and what is it that you
would like the AGD to do for you? How would you like to see this case resolved?
II Have you enclosed all pertinent correspondence and information?
III Have you contacted the carrier in an attempt to resolve this case?
A. Have you determined whether this is a contractual limitation? If so,
what does the contract state?
1. Did you speak with a dentist or a clerk?
Phone (_______) ________________________
a. Did you record the person’s/persons’ name(s) and telephone number, the date of your conversation, and the concerns/decisions discussed?
2. Is there someone in a position of higher authority that you should talk to?
a. Did you write to the president and/or chairperson of the company?
IV Have you asked the patient to intercede?
A. Has the patient notified his or her employer, benefits manager, and/or union
B. Do you have copies of that correspondence? (Make and keep copies of all correspondence)
V Is an internal appeal process available?
A. Has the patient used it?
VI Have you notified the following organizations in the sequence shown below?
A. Local dental society
1. Is peer review a viable option?
B. State dental society
1. Do local relationships allow for direct intervention?
C. State insurance commissioner
1. Is the carrier operating under a state issued certificate of insurance?*
2. Is it a self-funded plan regulated by ERISA?*
D. American Dental Association’s Council on Dental Benefits
E. Academy of General Dentistry’s Dental Practice Council
1. Do you agree to inform the AGD of any change in the disposition of this case, such as a resolution or withdrawal?
2. Do you agree to inform the AGD of any further communication
on the part of the carrier, the patient, or yourself?
VII Have you and/or your patient sought legal advice?
A. Have you and/or your patient discussed the possibility of resolving the matter through the courts?
*NOTE: A Certificate of Insurance is regulated by the State Insurance Commissioner and the State’s insurance laws. The patient may contact the department of insurance regulation or whatever regulatory agency exists for these purposes.
Self-Funded Plans are regulated by ERISA (the Federal Employment Retirement Income Security Act). Plan participants have a right to examine all insurance documents in the plan administrator’s office at no charge. Copies of documents can be obtained for which there may be a reasonable charge. If the claim for benefits is denied in whole or part, the plan administrator must provide a written explanation of the reason for the denial. The patient has the right to have the claim reviewed and reconsidered. There are steps that can be taken to enforce those rights. These include filing suit in a federal court or seeking assistance from the nearest area office of the U.S. Labor-Management Services, Department of Labor. Some concerns, such as coordination of benefits, may be appropriately communicated to the state insurance commissioner.
AGD Dental Practice Council
October 21 and 22, 2005
Complaint Reporting Form:
The AGD has adapted the Complaint Resolution Form used by the ADA in its third-party problem resolution program in order to assist constituent dental care chairpersons in reporting local problems to the national organization. Upon being notified by a member that he or she is experiencing difficulty in satisfactorily resolving a complaint with a third-party carrier, you should first make certain that the individual has followed the AGD Checklist for Resolving Problems with Carriers and then determine what support you, as the Constituent Dental Care/Practice Chair, can provide. Once you determine that all possible avenues have been explored, you should copy and complete the following Complaint Reporting Forms and submit it, and all relevant background information, to AGD Headquarters. Staff will then review the situation and determine what future action is appropriate. You should also notify your state dental association about the problem.
AGD COMPLAINT REPORTING FORM
Information Only; No Action Required: Yes ___ No___
Desire Assistance: Yes ___ No___
Last Name First Name ___ M.I. ____
AGD Member # Region/State
Office Phone ( ) Home Phone (_______)_______________________
INSURED INFORMATION (SUBSCRIBER):
Last Name First Name ___ M.I. ____
City ___ State __ ZIP Phone (_______)__________________
Date of Original Claim: __ Social Security # __________________________
PATIENT (IF DIFFERENT FROM SUBSCRIBER):
Last Name First Name M.I. _____
Relationship to Subscriber: Self (1) Spouse (2) Child (3) Other (4) ____
City State ZIP Phone (_______)_________________
Please submit, with this form, an authorization for release of patient information that complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is signed by the patient or an authorized representative, prior to the release of any information related to the patient or this claim, including, but not limited to charts, x-rays and other records of treatment, to the Academy of General Dentistry. Patient information that is not accompanied by a HIPAA compliant authorization for release of information, signed by the patient or an authorized representative, shall not be accepted or considered.
EMPLOYER INFORMATION (Please complete the following information if it is known):
City ________________________ State ZIP Phone (_______)_________________
Benefits Contact: ___________________________________ Phone (_______)_________________
THIRD PARTY INFORMATION:
Policy # _____________________________________
Name of Insurance Company: __________________________________________________________
City _______________________ State Zip Phone (______)__________________
Contact Person: Phone (______)___________________ Plan Type _____
NATURE OF COMPLAINT—CHECK ALL THAT APPLY:
Lost/Misplaced Claim (LMC) Dentist Consultant Review (DCR)
Lost/Misplaced Radiographs (LMR) Unqualified Claim Reviewer (UNR)
Unauthorized ADA Code Change (UCC) Coordination of Benefits (COB)
UCR Fee Dispute (UCR) Explanation of Benefits (EOB)
Delay/Lack of Response (DLR) Treatment of Relative (TOR)
Assignment of Benefits (AOB) Denial of Claim (DEC)
Other (OTH): __________________________________________
NATURE OF THE PROBLEM:
In your own words, describe the details of the problem. If more space is needed, attach additional sheets. Include all supporting documents: letters, claims forms, explanation of benefits (EOBs), remittance advice, etc.
EFFORTS TO RESOLVE THE PROBLEM (Describe what you have done to resolve this conflict):
The Academy of General Dentistry
Director, Dental Practice Advocacy
211 East Chicago Avenue, Suite 900
Chicago, IL 60611-1999
Date Complaint Date
Entered Deposition Resolved Region/State _________
As your Constituent’s Dental Care/Practice Chair, you must communicate effectively with third-party carriers. When assisting members, it is always best to have a copy of all documents related to the situation before initiating any activity. The following pre-approach letter, designed by the Dental Practice Council, requests the carrier to explain the specific cause for the benefit denial/reduction. This letter may assist you in gathering pertinent facts and allow you to objectively analyze the situation. If you are already aware of the specific reason for the denial/reduction, you need not use this letter but rather may move onto another, more appropriate text.
Draft of a Pre-Approach Letter
Name of Carrier Executive
Name of Carrier
Complete Street Address
City, State, ZIP
Dear (Insert Name):
A member of our organization, Dr. (Name), has shared with us your (denial/reduction) of benefits for his/her patient M/M (Name). We are writing to you on behalf of Dr. (Name) to request the specific reason for this decision.
In order for us to gain some valuable information, which might assist us in resolving this problem for our member, we would appreciate a response from you as soon as possible, hopefully by (date).
Constituent Dental Care/Practice Chair
Academy of General Dentistry
Benefit Exclusion Clauses:
AGD membership surveys have indicated that 70.2 percent of responding general dentists reported that they have been denied payment of benefits for providing certain services. When a member of your constituent advises you that a carrier’s policy includes benefits exclusion clauses, your best approach may be to direct a polite and informative letter to the carrier pointing out the policy’s shortcoming. Be certain to send copies of the letter to the member, to the Director, Dental Practice Advocacy, at the AGD, and the individual at the state dental association who is responsible for dental care issues. A sample letter follows.
Draft Response to Benefit Exclusion Clauses
Name of Carrier Executive, Title
Name of Carrier
Complete Street Address
City, State, Z
Dear (Insert Name):
One of our members, Dr. (insert name), has expressed concern that (insert carrier’s name) dental insurance policy as held by (insert employer’s name) will reimburse plan participants for (specify type of treatment, such as endodontic, orthodontic, periodontic, etc.) dental treatment only when it is rendered by a (insert type of specialist, such as endodontist, orthodontist, etc.). We are attaching copies of the correspondence our member has provided us, which includes notification that (insert carrier’s name) will not pay for this treatment unless it has been performed by a specialist. It would seem to us that the patient is being penalized for going to a general dentist who felt sufficiently qualified to deliver this therapy without having to refer the case to a specialist.
Select text as applicable to the situation.
There are many areas of the country that have few, if any, dental specialists. According to a recent survey of Academy of General Dentistry (AGD) members, nearly (insert appropriate figure from the chart that appears at the end of this chapter) percent of responding general dentists perform this type of treatment. By limiting the availability of these services, the price of this treatment may greatly increase as fewer dentists are available to render these services, or some individuals requiring treatment will find it extremely difficult to locate dentists to perform the necessary procedures.
It is the nature of the state regulatory agencies to license general dentists to perform all phases of dentistry and to give them the discretion to determine when a case should be referred to a specialist. Referral should be at the discretion of the treating dentist.
As an organization of 35,000 general dentists which fosters continuing education for general dentists, the AGD encourages its members to continually update their knowledge so they can effectively deliver patient treatment. We urge you to change this discriminatory policy which has the potential to create so much dissatisfaction for the subscribers to this dental benefits plan. We look forward to hearing from you soon.
Constituent Dental Care/Practice Chair
Academy of General Dentistry
Limitation of Benefit Based on UCR:
When patients claim that they have been overcharged because your fee for providing treatment exceeds the amount covered by their dental plan, the best response is usually to advance patient education. Make certain that the form your practice uses to record patients’ medical histories clearly states that any difference between the fee charged and the benefit paid is due to limitations in the individual’s employer’s benefit contract, and that any unpaid funds are the patient’s responsibility.
When a patient notifies you that his or her benefit is lower than your fee for service, explain in writing that the treatment plan developed and followed was based on what was in the individual’s best interest for maximum improved or maintained oral health care, not on the basis of what services or fees were approved under the patient’s dental insurance program, which frequently provide less than optimal benefits. Inform your patient that fees are based on practice overhead, the treatment plan selected and the time involved in providing appropriate dental care. Note that it is in no one’s best interest to compromise recommended treatment solely to accommodate a third party’s maximum benefit allowance, which may barely be adequate, much less optimal. Indicate that you are willing to review the treatment plan and the rationale for your professional judgment regarding this case and how it might differ from the third-party carrier’s position. Let your patient know that you base your treatment decisions upon your professional judgment, regardless of whether the individual is covered by an insurance plan. The insurance carrier may be basing its fees on out-of-date information or it may not have taken into account certain local factors that may affect the fees for various services.