GDA Action September 2019

10 • September 2019 THE FOREGOING IS NOT INTENDED TO BE LEGAL ADVICE AND IS FOR INFORMATIONAL PURPOSES ONLY. PLEASE MAKE SURE YOU CONSULTWITH A GEORGIA LICENSED ATTORNEY BEFORE PROCEEDINGWITH ANY COURSE OF ACTION. Q: Is there anything my office can do if an insurance company sends the reimbursement check to the patient for dental treatment performed in my office? An “assignment of benefits” issue is one of the most common problems we hear from GDA members, particularly in situations where the dentist may not be an in-network provider with the patient’s dental insurance plan. In most instances, a dentist will tell us that the patient has told her insurance company to send the reimbursement check to the practice, but the insurance company ignores the request and sends the check to the patient, who may or may not realize that the payment was intended for the dentist. The patient then deposits the check and spends the money, or the dentist’s billing team has to chase the patient until she brings it to the office. It is a frustrating situation to say the least, and puts the practice directly at odds with the patient. Georgia already has a law on the books requiring an insurance company to adhere to a patient’s request to have the reimbursement check sent to the provider: “§ 33-24-59.3. Payments sent directly to health care provider by insurer (b) Any other provision of law to the contrary notwithstanding, if a covered person provides in writing to a health care provider, whether the health care provider is a preferred provider or not, that payment for health care services shall be made solely to the health care provider and be sent directly to the health care provider by the health care insurer, and the health care provider certifies to same upon filing a claim for the delivery of health care services, the health care insurer shall make payment solely to the health care provider and shall send said payment directly to the health care provider. This subsection shall not be construed to extend coverages or to require payment for services not otherwise covered.” However, as with any law, there are caveats to the general interpretation of this statute. First, the statute requires that the patient’s request be provided to the healthcare provider “in writing,” and that the “health care provider certifies to same upon filing a claim for the delivery of health care services.” Accordingly, you may wish to verify if your current intake paperwork includes a written and legible assignment of benefits statement directing that all insurance reimbursement payments associated with a patient’s dental treatment be sent to your practice. Moreover, your staff should ensure that the patient signs it and includes the assignment of benefits statement with your claim submission packet. One possible way to help reduce the chances of a denial would be to get the patient to sign an assignment of benefits statement corresponding to each claim your office files on her behalf. The second caveat is more of a “legal technicality” that insurance plans often use to circumvent Georgia’s law, which stems from the fact that certain types of health insurance plans are regulated by federal law (ERISA plans), while others are regulated by state law. While I will not get further into the weeds on how or why this distinction exists, one of the most important things to know to about how to distinguish between ERISA plans and state law-regulated plans is whether the plan is “fully-insured” or “self-funded.” Fully-insured plans are regulated by state law, while self-funded plans are governed by federal law/ERISA. “But how can my staff identify the insurance plans that are required to follow Georgia law?” Currently, this can be a laborious and time- consuming process. During the GDA’s discussions with members of the Georgia Department of Insurance, we learned that the Department currently does not track this. When GDA staff receives calls from member dentists, we often advise them to ask the patient to contact her employer’s HR department (assuming this applies) and have the HR coordinator answer this question, since obtaining accurate information from an insurance company, especially for out-of-network providers, can be even more challenging. Fortunately, one of the pieces of legislation passed by the GDA’s Government Affairs Team during the 2019 legislative session should make this verification process less burdensome for Georgia healthcare providers. Starting in the 2020 renewal cycle, all health insurance cards issued in Georgia must contain a statement that the patient’s insurance plan is “subject to regulation by the Georgia Insurance Commissioner” if the plan is fully- insured and thus regulated by state law. Accordingly, your staff should be able to more easily identify state regulated plans when the patient presents her insurance card at an appointment and report violations of Georgia’s insurance laws to the Georgia Department of Insurance. If you have any questions about this article, please contact scott@gadental.org or call 404.636.7553. FROM THE GC’S DESK Continued from page 9