NMDA Journal Winter 2019-20

14 New Mexico Dental Journal, Winter 2020  continued from page 13 happens as a result of errors on the claim or changes to a patient’s coverage which they didn’t know or inform the office about. Even more frustrating are claims that were initially approved and paid, but then recalled at some later date as a retroactive denial. These are usually the result of a processing error on the part of the dental benefits administrator and often come many months or even years after the claim was paid. While this may come as a request for a refund to offices, most of the time the amount is sim- ply deducted from the payment of a future claim. Not only are offices out revenue they were counting on, but the accounting on these random deductions is complicated by claims that have been long closed. Taxes may have been paid and patient balances collect- ed. Although patients may be responsible for the unpaid claim, they may be quite resistant to now pay more on a bill they considered closed and often there is little recourse to challenge the company’s decision. Years after the fact it can be difficult to access relevant documentation. Patients’ employers have of- ten changed insurance companies or HR staff has changed. Offices may be caught in the middle facing lost revenue versus keeping a patient happy. Technically, the third-party payer’s issue is with the patient. Dentists have already de- livered the care and are rightfully entitled to payment. Payer’s force dental offices to become their “collection agencies,” a role which is neither desired nor deserved. Some states have passed legislation that limits the amount of time that may pass prior to a retroactive denial or require payers to collect from the patients themselves. Assignment of Benefits Since the process of filing dental claims can be difficult because knowledge of coding and processing requirements is necessary, pa- tients prefer that dental offices perform this service. In exchange, patients allow offices to directly collect the claim payment that is applied to their accounts by assigning their benefit to the dentist. Patients appreciate the help and convenience. Dentists appreciate the timely payment and not having to collect from the patient. Dental benefits companies are not required to accept the patient’s assignment. Some managed care companies have established policies that prohibit patients from assigning benefits to a dentist that is out-of-network. There may be many reasons why dentists choose not to contract with certain compa- nies or plans. Plan policies that do not allow assignment of benefits do not benefit pa- tients and only serve to pressure dentists to sign contracts they would not otherwise sign. Some states have passed legislation that requires dental benefits companies to honor a patient’s assignments when all relevant requirements are met. Patients should have the right to make this decision and have it honored and carried out, just as dentists should have the right to sign the contracts they choose. Disallowed and Non-covered Services Even before the advent of managed care, dental benefits companies adopted coverage and processing policies that limited the kinds of services they would cover. In those circum- stances, dentists were typically free to offer these non-covered services to patients who could elect to pay for them out-of-pocket. Managed care can enforce some of these restrictions on contracted dentists through provisions in these contracts which allow the company to deny treatment as “unnecessary” and prohibit dentists from collecting from the patient. Dental offices are frustrated by being un- able to collect for services they have already provided, even when patients have already agreed to pay for them. Patients may want services that they and their dentists have deemed necessary only to be faced with of- fices being unwilling to proceed with proce- dures they may not be paid for. New Mexico passed legislation in 2009 which prohibits dental benefits companies from creating fee limitations on procedures they choose not to cover, which allows dentists and patients to negotiate fair fees for pro- cedures that the dental benefits companies exclude from coverage. This statute does not apply to plans that are outside the state’s ju- risdiction. These plans are under federal ERISA jurisdiction which includes all interstate and self-funded plans and constitute the majority of plans dentists encounter. Several states have passed legislation that requires dental benefits companies to give offices the choice of receiving payment via check, virtual credit card, or direct electronic deposit, if offered. Offices would then have the choice to receive payments via the method most conducive to their businesses.