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Did you know? Insurance carriers can dictate fees for non-covered services?!

“In-network” dentists, meaning dentists who have signed a contract with an insurance carrier, may not realize that their agreements may feature a restriction on fees for services not covered by the insurance carrier. Even though an insurance carrier will not pay toward a non-covered service or procedure provided after the patient’s annual maximum has been exhausted, they dictate the fee that the network dentist may charge. The dentist is not able to charge his/her “normal” fee, and in some cases may also be restricted in patient co-payment amounts. This practice is called “fee capping”.
Why would a dentist agree to this?
• The dentist wants to secure a reliable patient base during an economic downturn.
• The dentist already has a large population of patients with a “fee capping” plan. The “maximum allowable charge” feature may drive these patients to have more treatment accomplished, possibly off-setting the discount.
• The dentist is satisfied with the discounted fee.
• The dentist does not realize his/her contract includes this stipulation.

Surprisingly, “fee capping” may be imposed on both PPO providers and “premier” network dentists.

It is often a mystery how a carrier determines fees. Many refer to the payments they “allow” toward a procedure as “usual, customary, and reasonable” or UCR. However, in actuality, UCR might more accurately be termed “negotiated payment”. Typically an employer will select a plan that has the premium cost they want along with a benefit schedule they can accept. The payment that correlates to the premium and benefit selected are usually “negotiated” between the carrier and the employer. Therefore, the fee that is considered the “maximum allowable benefit” is a “negotiated payment” rather than “UCR”.

This summer the Rhode Island Dental Association was instrumental in the passage of a law in that state prohibiting insurance carriers from setting fees for dental services they do not cover.
Other states may see the passage of similar laws. In the meantime, dentists need to be aware of stipulations in the contracts they are signing. It is one thing to establish a relationship with a carrier based on mutual benefit. It is another to establish such a relationship without all of the facts.
(Help your patients understand the limited nature of dental insurance. Look at my patient brochure, “My Insurance Covers This….Right?” at )

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Comment by Thornhill Dentist on September 19, 2010 at 5:10pm
The dentist richmond hill is not able to charge his/her “normal” fee, and in some cases may also be restricted in patient co-payment amounts. This practice is called “fee capping”.
Comment by Carol Tekavec on August 28, 2009 at 1:15pm
Hi Christine,

Thanks for the kind words. I live and work in Pueblo, Colorado. It is a nice small town about a one and a half hours drive from Denver.

Comment by Christine Taxin on August 26, 2009 at 10:06pm
Hi Carol, I have always followed you and have followed in your footsteps. I also teach insurance and rules but you are the very best. Thanks for always sharing and teaching us. Are you in Chicago?
Comment by Darrell Pruitt on August 7, 2009 at 11:17am
Nice article, Carol. Perhaps it was too nice.

I also followed the Rhode Island fee-capping story, as well as reported about it here on PennWell blogs. (See “Delta Dental suffers hits on the Internet,” July 7)

I recognize the dental benefits company in Rhode Island whose name you didn’t mention. It is Delta Dental. It used to bother me to mention names as well. But I got over it.

I hope it wasn’t out of respect for the institution that you avoided naming Delta Dental. If so, let me assure you that your respect is widely misplaced. Delta is simply a sleazy discount dental broker that flatters itself by calling itself an “insurance company.” The misnomer is a slick PR upcode meant to confuse busy employers who quickly purchase Delta’s products for employees, without the benefit of a clue.

Trust me. DDPA CEO Kim E. Volk has proven that she holds no respect for us or our patients. In turn, I have nothing but contempt for her and her company. She is reminded of my opinion every time she, or anyone in Congress, googles her name because my article “Kim E. Volk and dentists to discuss Delta - sooner or later” is her number 1 hit.

I think that little piece of work shows that I am doing my part to clean up the community rather than merely complaining about the garbage in the streets.

If we continue to reward Volk’s selfish ambition by treating her like she is above reproach, how can we ever hope to run unethical people like her out of OUR dental industry?

I interpret the Hippocratic Oath to mean that I am obliged to protect my patients any way possible. If that means becoming nasty with bureaucrats who would harm them for profit, so be it. That makes it all the more fun, actually.

I recently read that United Concordia is attempting the same trick. (Doesn’t that make you wonder what happened to the Sherman Anti-trust Act?) An article was posted on the ADA News Online this week in which hard-hitting ADA reporter Arlene Furlong exposes UCCI’s own attempt to limit what a dentist charges for even non-covered procedures. It is titled “United Concordia caps rates nationally for PPO.”

Let me describe why these tricks are not fair to PPO dentists who may already be struggling to keep from going bankrupt because of United Concordia clients’ 30% discounts on the procedures the plan covers. If a large percentage of a dentist’s practice are UCCI patients, the dentist cannot afford to break his or her contract with UCCI without going broke in a hurry. And if the dentist is not permitted to raise his or her fees to cover the expenses of running a dental practice, who in this triangle of misplaced allegiances unknowingly suffers? Is it the dentist, United Concordia or the patient? Hint: Ethics aren’t free.

I know it is painful to think about, for honorable dentists as well as patients, but if a patient is told by a dentist that a tooth needs a filling, how is he or she to know for sure without visiting another dentist? It is a real hassle for a patient to get a second opinion for many reasons, and nobody can verify the need for a small filling without the patient sitting in a dental chair. This builds into the triangle a significant barrier to accountability. Unaccountability allows managed care patients to be hurt when preferred providers are squeezed between overhead and fee caps by United Concordia and Delta Dental.

Let’s not kid ourselves about the price of ethics. If a dentist finds him or herself trapped, managed care patients will reliably suffer the most - long before the dentist moves out of the area or declares bankruptcy. Yet the innocent and naive employee who is “given” a provider list as part of an employment package is always the least informed about their dentist’s business arrangement with the discount dentistry broker. Virtually none of them are told that United Concordia’s 30% discounted fees mean a 70% pay cut for their dentists. If employees pay is cut 70%, what naturally happens to the quality of the work?

For the safety of dental patients nationwide, we must drive dishonest businesses like Delta Dental and United Concordia out of our neighborhood. If we each encourage our Congressmen and women to repeal the McCarran-Ferguson Act of 1945, the FTC will put a quick halt to this crap through enforcement of the Sherman Act. Otherwise it will be a state-by-state battle, and I’ll have to tear into bozo CEOs and vice presidents again and again. That’s OK too. I just found two fresh targets in Furlong’s article named Karen Whitesel and Jon Seltenheim.

Regardless whether we halt collusion between UCCI and Delta using anti-trust laws, we must never resist holding sleazy business leaders like Kim E. Volk personally accountable to their clients, because nobody else will take a stand on their behalf. Only dentists and staff care for dental patients. All others only want their money.

D. Kellus Pruitt DDS

Now, excuse me while I take care of some unfinished business: You must answer to me, Kim E. Volk. If you haven’t done a vanity search recently, three out of ten hits on your first page are my comments, and I haven’t tinkered with your reputation in more than a month. If you stay silent, eventually your whole first page will consist of my invitations, and they will only get nastier. You’re not nearly as special as you think.

As for the two poor slobs from United Concordia who allowed themselves to be quoted in Furlong’s article, corporate vice-president Karen A Whitesel and senior vice president Jon Seltenheim, I’m going to start tinkering with your Internet brand within hours. You should never again bring your disrespect of my profession onto the Internet because I will do everything I can to ruin you using nothing more than transparency.
Comment by Penny Anderson on August 4, 2009 at 3:57pm
I thought I knew a lot about dental insurance, Carol, but this was an eye-opener to me! Dentists need to get out their magnifying glasses and read every single word of contracts they sign with third-party carriers.


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