New bill limits insurance companies ability to take back benefits
By Dr. Stephanie McGann, DMD FAGD, Columnist, The Times
When trying to decide what to name this month’s column I was stumped for awhile. Yet it seems that we are going to spend a small time talking about the current state of healthcare legislation and then laughing at the lastest fad.
The truth is that what I am going to share with you this month is not new. Under the current system -health care insurance carriers have an unlimited time to re-evaluate claims they have previously paid and retroactively deny them. This means that a patient who has services rendered and paid for all or in part by their insurance can find themselves in a situation where the insurance carrier has demanded that the provider return all or part of the payment to the insurance company and then unfortunately the patient may subsequently be responsible.
Now, usually this happens when a carrier processes a claim but the employer then did not renew the coverage for the time period in question. Sometimes the demand for refund is because the carrier processed a claim twice and issued two payments. Unfortunately in some cases the demand is based on a re-review. The criteria for coverage may have changed and now they are effectively changing their mind on providing benefits after the fact. No, that pretreatment estimate (predetermination) we have in writing from the carrier is not binding in any way.
Currently, there is legislation in Pennsylvania that would limit the time frame to review and retroactively deny patients claims to 12 months. (SB 554 and HB 1178)
As a small business owner it is an expensive event when a claim is retroactively denied. First – we appeal the decision on behalf of our patient. There is substantial paperwork involved – in addition the awful communication with our patient who may have had dental work done years ago and now suddenly their carrier is demanding their money back. In some cases the insured is no longer with this particular insurance company it gets very complicated and messy. All of this spells time for the small business owner. These costs only increase the cost of healthcare.
As a patient – this should be frightening. Reach out to your Pennsylvania legislators (after the dust of the election has settled) and ask them to please support SB 554 and HB 1178. Protect your pocketbook and hold your insurance company to kind of standards in Pennsylvania that they have in many other states.
On a lighter side – have you heard of lolz? There are a number of games on the market for this holiday season that feature – of all things – dental cheek retractors. Yes some brilliant marketing person realized how silly someone sounds when the try to speak with retractors.
Speak out – by Hasbro
Watch Ya’ Mouth
LOLz
Mouthguard Challenge
Lipless
These are just a few of the variations on this new game phenomenon that popped up on Amazon. The good – I’m sure it’s funny to watch and even funnier when speaking. The bad – unless you plan on once and done it can be a great way to share bacteria and viruses.
If you really are going to use this as a party game be sure each player has a new unused “game piece” and dispose of it after the game. Refills can be purchased. If the plastic retractor causes pain immediately remove it and find something else to play with. Do not try to eat or drink with the retractor in place. It is my hope that this is a passing fad and will not cause any long term damage. The retractors may be too large for individuals with small oral openings and may cause tearing or other facial damage. Personally, I would steer clear of this one.
Dr. Stephanie McGann, who has more than two decades of dental practice experience, is a resident of the Unionville area and along with her partner, Dr. Marie Scott, operates The Brandywine Smile Center, a family-friendly dental practice in Concordville. Dr. McGann has opened a new practice in Valley Township, Rainbow Valley Dental. She is a Fellow of the Academy of General Dentistry.
