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Opinion: Assignment of Benefits Strikes Again

5/14/2012

By WILLIAM B. RISK, DDS

IDPAC Chair

Last November a long-time patient came to my office with a four-unit bridge in her hand. She had not visited the office for a while due to health concerns and, during that time, the crown on the upper-left second molar had become loose.

She was on medication that reduced salivary flow, and the resulting decay was quite extensive. Upon examination it became obvious that if the bridge was to be salvaged, or even remade, root canal therapy would be necessary. I began the root canal, and we made an appointment for its completion. We then billed her insurance company for the procedure.

At her next appointment we decided that, since the tooth would still be a questionable bridge abutment even after endodontic therapy, we would remove the tooth and restore the upper-left quadrant with two implants. We removed the tooth, and only charged the patient for the extraction, not for any of the root canal treatment. We billed her insurance company for the extraction and also notified them that the root canal would not be done.

But, it was too late. The check had already been mailed. My patient paid for the work that was completed, and subsequently two implants have been placed.

In March I received a certified letter from my patient’s carrier demanding a refund of the $612 it had paid for the root canal, since the tooth was extracted. This refund was to be made within 30 days.

It must be remembered here that I am not a preferred provider for any insurance company, so I don’t always receive payment directly from them. In this case I did not receive any checks from my patient’s insurance company.

Not only are they demanding a return of the money which I didn’t receive, but if I dispute their findings I am to send complete patient records (both treatment and financial) and duplicate radiographs for them to determine if they owe a refund.

A rather interesting aspect of the threat is what will happen if I did not comply and remit the $612. If it is determined that a refund is owed, it will come from the automatic deduction process. I assume this means that the patient’s benefits will be jeopardized and withheld until the insurance company feels the refund has been obtained.

What’s wrong with this is, what if my patient sees another dentist during this withholding period? Will she not have complete benefits? Why didn’t her carrier contact the actual check payee and ask her to return the money?

This is one more example of why Assignment of Benefits legislation is necessary. With assignment of benefits, the insurance company can deal directly with the health care provider if there is a question or a dispute over the patient’s treatment. The patient’s benefits are never in jeopardy by having a deduction period. Because the insurance company would deal directly with the provider, the patient could still see another dentist and still have the benefits his or her premiums provide.

To be continued..

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