In your practice, have you experienced what you regard as insurance-industry intrusions on the relationship between you and your patients?
On Aug. 15, the ADA filed a class-action lawsuit against one of the nation’s largest dental insurers that is intended to halt what the Association sees as unlawful interference in the dentist-patient relationship.
The three-count suit originally filed in Northern Illinois U.S. District Court alleges that Aetna Inc. and its subsidiaries knowingly established a schedule of "usual, customary and reasonable" fees using a database that was "unsuitable" for that purpose—an alleged breach of contract under the Employee Retirement Income Security Act of 1974, the federal law that governs group health plans.
In preparation for the lawsuit, ADA News published in May 2000 a page-one story headlined "ADA Seeks UCR Data." The article called for member dentists to tell the Association about problems they have had with dental insurers, particularly those related to claims processing and payment.
The ADA Division of Legal Affairs logged each of the hundreds of complaints it received and studied the documentation the dentists supplied. Eventually, two ADA members—Dr. James B. Swanson, a general dentist from Palos Heights, Ill., and Dr. Michael B. Dayoub, a periodontist from Savannah, Ga.—agreed to join the ADA in the suit as representatives of the class of "out-of-network" dentists allegedly wronged by Aetna Inc. and its subsidiaries—Aetna-U.S. Healthcare Inc. and Aetna Life Insurance Co.
In September, JADA asked if readers have experienced what they regard as insurance-industry intrusions on their relationships with their patients. Ninety-seven percent said yes.
Several gave examples, including needing to obtain preauthorization from insurance companies before performing procedures, being told "payment is denied because treatment is not necessary" and having code numbers "downgraded."
"To me," said one reader, "changing code numbers is practicing dentistry without a license."
Almost all of those who provided comments said the intrusions affect the day-to-day activities of their practices. "The friction created by insurance companies’ interference leads to more anxiety in patients and staff in my practice than anything else," said one reader.
"Almost daily we are put at odds with our patients because of insurance companies policies, fee schedules and use of usual and customary phraseology," said another.
Many said they felt the biggest intrusion is the "usual, customary and reasonable," or UCR, rates used by the insurance carriers to determine payment.
"The statement ‘exceeds the usual and customary fees’ has made patients think that the dentist is overcharging, not that the insurance carrier is underproviding," said one reader.
"We have experienced intrusions, as well as the controversial UCRs used by insurance companies, which match no one’s fees I’ve ever met," said another.
Other readers said they feel the trust between them and their patients is being eroded. "I am very resentful of insurance carriers questioning in a manner that reflects a distrust of the dentist that obvious dental problems need to be treated," said one dentist.
"Several times I received denial of services because of they say my fees are higher than UCRs, which obviously creates a feeling of mistrust in my patients," said another.
Only 3 percent of respondents said they have not experienced insurance-industry intrusions in their dentist-patient relationships.
"Although I believe it occurs, I have not witnessed it," said one.
