Policing illegal or unethical insurance practices

When you're up against a dental insurance carrier who is repeatedly denying claims, it can feel hopeless—but it's not. It is possible to fight back. Here's how.

Feb 8th, 2017
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When you're up against an insurance carrier who is repeatedly denying claims, it can feel hopeless—but it's not. It is possible to fight back. Here's how.

Who polices questionable insurance practices? Let me qualify that question. Let's say you perform scaling and root planing on an adult patient who has not brushed or flossed his teeth for 10 years. When the explanation of benefits (EOB) reaches your office, the insurance carrier informs you that its dental consultant disagrees with the diagnosis, and the claim is denied. I have seen several EOBs that go to the extent of telling the patient that he or she should speak to the dentist about the misdiagnosis.

Furthermore, almost all EOBs provide no statement of correction or recourse—a simple denial is all you get. Many argue that the insurance carrier would rather have you perform a prophy instead of the more appropriate treatment of scaling and root planing. The key question here is, if you were to perform a prophy on this patient, would you be considered for malpractice? If the answer is yes, then why are insurance carriers not held to that same standard? Who polices these types of unfair, unethical, and often illegal practices? Allow me to spoil the ending—you can!

Who are the Goliaths of your world?

You may recall the stories of David and Goliath; the Spartan army, led by King Leonidas, at the Battle of Thermopylae; or my personal favorite, the Battle of Baltimore at Fort McHenry. On September 13, 1814, British warships delivered a downpour of rockets and mortar shells onto Fort McHenry in Baltimore Harbor. This relentless pounding of the American fort lasted 25 hours. Weeks prior to this attack, the British burned the Capitol, the Treasury, and the president's house. Needless to say, America's defenses were crushed and any hope of victory was shattered.

Francis Scott Key, a 35-year-old American lawyer, witnessed the barrage of Fort McHenry from just eight miles away. "It seemed as though mother earth had opened and was vomiting shot and shell in a sheet of fire and brimstone," Key wrote. Given the magnitude of the attack, Key was certain of a landslide British victory. But in the "the dawn's early light," Key saw the American flag, not the Union Jack, waving bravely over the fort—the Americans had won.

During the attack of Fort McHenry, Key penned a poem we now call "The Star-Spangled Banner." Many historians believe that Key's poem restored the confidence of those who were defending the "land of the free and the home of the brave," despite the scale of the attacks by British forces.

Giving in is not an option

Much like David, the Spartans, or the American soldiers defending Fort McHenry, we all have moments of doubt, fear, and uncertainty—especially when dealing with insurance carriers. Allow me to be the bearer of good news by informing you that you do not have to accept unethical or illegal decisions by insurance carriers. They hire licensed dental consultants and attorneys to advocate their own interests and often claim that you are contractually obligated to follow what they say. But if they were to tell you that you are contractually obligated to take a dive off of the George Washington Bridge every Saturday, would you do it? I didn't think so!

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Insurers' advantage is that when they release their version of mortar shells and rockets onto dental practices, most dentists retreat. You may fear that insurers have far more resources and attorneys to make your life hell if they wanted to. Most dentists do not fight insurance battles beyond sending one to three appeals per denied claim. Many do not know where to start or how to effectively challenge an unethical or illegal insurance action. As you read the next few paragraphs I want you to know that you should not fear insurance. If you are practicing dentistry honestly and ethically, you can and will win the battle in policing unethical and illegal insurance practices. Allow me to outline how you can engage in self-advocacy and win.

Is there a strategy to effective self-advocacy?

Earlier this year, my colleague Tessina Barney engaged in a battle with a large national insurance carrier. Like most dental practices who participate with certain PPO networks, services such as periodontal maintenance, scaling and root planing, and crown seats were consistently being denied by this specific insurer. Tessina discovered a pattern that after the fourth appeal, the insurance company would finally pay up. Frustrated with this process and knowing how much this was costing her employer in additional payroll hours, Tessina contacted my office and we discussed hiring an attorney. Upon receiving counsel from the retained attorney we learned that, unlike many communities, Utah was not a right-to-action state. In other words, we could not pursue legal action.

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.

To Tessina, this was "the dawn's early light" and first signs of hope in challenging an apparent barrage of unsolicited abuse by this large carrier. Weeks later, Tessina received a phone call from the commissioner, who reported that his office had investigated her claims and found that the insurer was in violation of Utah's rules and regulations. Furthermore, the commissioner cited this carrier for violating the state's guidelines on payment of claims for health-care services that have no defect or impropriety. In addition, the commissioner issued a fine to this particular insurance carrier for each reported violation. As a result, claims administrators from this PPO network began paying claims the first time they were submitted. As I write this article, Tessina reports that there have been no violations since this issue was resolved. In short, this victory was sweet and well celebrated!

How to defend quality care when it is repeatedly denied by insurance

To take advantage of effective self-advocacy, first you must remove the fear of the Goliaths of your world. While it is not uncommon for dentists to engage their states' insurance commissioner, it is almost certain that many complaints fall on deaf ears. For most of you, the only option is to work through your commissioner. Here's how you can effectively seek his or her help:

1. Do your best dentistry. Quality care matters! It's nearly impossible to defend yourself against complaints or malpractice suits when quality care is not there. Simply stated, quality care should be at the forefront of your mission statement.

2. Know the CDT codes. Do your definitions of dental services match CDT? It is my understanding that insurance carriers lease the CDT guidelines from the ADA and use those coding definitions to process claims. If your understanding of dental treatment does not match CDT, you will likely lose every argument when it comes to claims appeals.

3. Find a pattern of abuse. Before Tessina approached the insurance commissioner, she had 10 examples of questionable actions by a particular insurer. Those 10 examples served as sufficient evidence for the commissioner to find fault with the insurance carrier in question.

4. Embroider "relentless" on your sleeves. While "impossible" is an opinion, it is not an option. In states like Utah where you cannot sue an insurance carrier for questionable or illegal actions, your only option may be to work through the insurance commissioner. Do not give up and do not give in!

5. Let the insurance commissioner advocate. Since the insurance commissioner is part of the Department of Justice, always approach the commissioner on behalf of your patients. Insurance benefits are purchased to provide appropriate dental care when insured patients need it. The commissioner's purpose is to enforce actions by insurance carriers who unnecessarily block patients from receiving the benefits they or their employer paid for.

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Building a shelter against the mortars

I can't claim to understand what those soldiers experienced at Fort McHenry in 1814. After 25 hours of pure terror, what joy it must have been for the surviving soldiers to find that "our flag was still there!" That piece of history, combined with the American pride deep in the hearts of all those patriots, made this great nation what it is today-a nation where dentistry continues to thrive and a nation where the underdog always has a fighting chance. I firmly believe that when you are doing your best work and following the law, you can be fearless in defending the financial integrity of quality care. You can be relentless in building a shelter against unnecessary abuse.


Benjamin Tuinei is president of Veritas Dental Resources, a company serving dentists seeking assistance in improving their insurance reimbursements. He has been recognized by several state dental associations and reputable CE institutions as "the authority" on PPO strategies and fee negotiating. Benjamin has worked with more than 5,250 dentists nationwide and has influenced more than $1.5 billion in newly negotiated revenue for his clients. He resides in Salt Lake City, Utah, with his family. For more, visit veritasdentalresources.com.

Editor's note: This article has been edited to correct an error in the date of the Battle of Baltimore. The original article incorrectly gave the year as 1843.

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