Question:
Are there any rules or statutes regarding insurance company interference in the
diagnosis, manner or modality with which I treat my patients?
Answer:
Mom comes in with a 14 year old boy who 23 months prior had an upper central
avulsed as a result of a baseball injury and reimplanted at that time. The
tooth was ankylosed and submerged. Patient also had a class II malocclusion and
lower anterior crowding.
Mom said that the insurance company for the baseball league agreed to pay for
all resulting costs of restoration and repair after the dental insurance had
been maxed out, including orthodontics, as long as treatment was commenced
within a 24 month time frame. She had a letter from the baseball league to
prove it. We got the necessary records and began treatment within the necessary
time frame, and agreed to send the bill to the medical insurance company, and
accept the benefits, as long as she agreed that if they declined the claim, the
family would be responsible.
The letter to the insurance company stated that the treatment for the ankylosed
tooth was a direct result of the injury, but that since we hadn't seen the
patient before the accident, we couldn't state conclusively whether he would
have need treatment had the injury not occurred (which is what they had asked.)
In addition, we sent a claim to the dental insurance company, although from
them we did not accept assignment. I got a partial down payment 'cause I was a
little suspect, but thought we'd be OK. She was so pleased with our office that
she brought us cookies after his first visit!
The patient had the first 3 appointmnets in my office, got his braces partially
in place, and then never showed up again. We got a denial letter from the
medical insurance company and called the mom to discuss it. She said that not
only had the medical insurance denied the claim, but they told her it was
because of the letter we had written and that they should stop treatment,
appeal the claim, and go to another orthodontist. Mom also told us that the
dental insurance had also denied the claim.
After doing a little checking, we found that the dental insurance had
reimbursed her for what she now owed my office. So that little falsehood got me
wondering if the medical insurance truly interfered here or was that an excuse
so they could continue to not pay me for the work I did do.
Assuming that the insurance company did interfere, do I have any recourse? The
patient is now in another docyor's practice, and wasted no time in slamming my
treatment plan and my work, so I know they're not coming back. I just don't
like being taken advantage of, nor am I happy about my reputation being muddied
by the insurance company, (if that's the case) or the other doctor. At this
point I'm not even sure he's an orthodontist.
If you can verify this I would be curious to see if the AAO legal dept.
would give you assistance.
My advice is decide if you want to pusue collection - give it to your staff
and forget about it. Life's to short to agonize over these cases. If the
doc isn't an orthodontist and treating what sounds like a screwed up case to
begin with, the mom will shortly be spending her time ragging about the new
office when treatment goes south and will forget she ever knew you.
I had one of these about a year ago. Post treatment and post trauma.
Repositioned the central, bonded temorary fixation, made new retainers,
signed contract, medical claim filed and never got a cent. I was certain
the central had a poor prognosis (future endo and a crown, extraction
probable) and decided to let it go. One of those I could just see them
coming back and blaming me for tooth loss after he caught a fastball in the
mou
