In politics, there are no winners

The dental profession and its political forces seem to have stepped upon some rather unstable ground. As one group plants the flag of victory, the other is retreating back to the high ground they once controlled.

Tom Limoli Jr.

The dental profession and its political forces seem to have stepped upon some rather unstable ground. As one group plants the flag of victory, the other is retreating back to the high ground they once controlled.

With some interpretations, the sword of HIPAA cuts both ways. Organized dentistry is celebrating the fact that benefits plans will soon be forced to accept and acknowledge — as well as process — claims based upon CDT codes. Is this a good thing? Let's take a closer look.

HIPAA legislation is mandating a singular code set for the identification of dental procedures. We will soon have only one set of acknowledged procedure codes to identify the services dentists perform.

In other words, dental procedures performed or supervised by dentists are only to be identified with CDT procedure codes. This is a great idea and I find nothing wrong with this legislative mandate. The administrative simplification will soon pay the bill to all the lawyers for their years of legislative rhetoric.

Well, where is the problem? The problem comes in when a benefit plan administrator is forced to adjudicate and pay or close claims based upon that same code set.

Are the political forces attempting to do away with the practice in which plan administrators frequently apply alternate benefit payments to noncovered procedures? If this is the case, someone had better tell the benefit-plan purchasers because they will soon be our individual patients.

HIPAA will not force benefit plans to in any way pay for services not contractually addressed in the plans documentation. As far as the amount the plan will pay goes, do you remember the childhood fable of "Jack and the Beanstalk"? How noble the actions of the townspeople in their attempt to do away with the giant! No longer would they be dependent on an outside entity. All they needed was control of the goose that laid the golden eggs. Sound familiar?

Do we not remember the characters and how the fable ended? Here is a short version of the "rest of the story."

Jack climbs up the beanstalk and takes goose from the giant.
Giant's magic harp no longer makes music.
Giant discovers missing goose and chases after Jack.
Jack climbs down the beanstalk with stolen goose.
Giant continues after Jack enroute down beanstalk.
Jack chops down beanstalk and giant falls to death.
Happy ending as Jack keeps goose and now thinks he controls flow of golden eggs.

It's easy to see in this analogy that Jack is a dentist and the golden eggs are insurance company money. The protective magic harp represents frivolous feel-good legislation brought about by fee-for-service lawyers and hollow lawsuits. They also make lots of noise, but provide very little protection. Some individuals (greedy, blood-sucking, bottom-feeding lawyers) are of the impression that the giant represents the evil insurance company keeping control of all the gold. But they are wrong. Why? Here's why:

* The giant does not make the gold.
* The gold comes from the goose.
* The goose is the purchaser of the benefit plan that distributes the gold.
* The giant takes care of the goose.
* And golden eggs are made only when the goose is cared for and happy.

What will happen if lawsuits do away with the concept of UCR reimbursement restrictions and benefit plans are legislated into paying out for more than was intended? Will lawsuits make those insurance companies pay us what we want? Have we forgotten that it's not the insurance companies' money?

It's the money of the benefit plan purchaser that is simply being administered by an insurance company, acting as a fiduciary. If the benefits industry is legislated into doing away with market-driven data, it will be replaced with straight-scheduled dollar amounts and prices to consumers will be driven down — not unlike prescription drugs in Canada.

Think of it this way. When a plan (purchased by an employer or employee) contractually specifies it will only reimburse up to $300 for a crown, what will that do to the validity of your $900 usual fee?

Think about it. Is the enemy of our enemy really our best friend?

Tom Limoli Jr. is the president of Atlanta Dental Consultants and the editor of Dental Insurance Today, a bimonthly publication that addresses third-party reimbursement in the dental office. He also is the author of Dental Insurance and Reimbursement Coding and Claim Submission. He can be contacted by phone at (404) 252-7808. Visit his Web site at www.LIMOLI.com.

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