Date |
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2/8/2017 |
Insights |
Policing Illegal Or Unethical Insurance Practices |
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Policing Illegal Or Unethical Insurance Practices by Benjamin Tuinei When you're up against an insurance carrier who is repeatedly denying claims, it can feel hopeless—but it's not. It is possible to fight back. Here's how. Who polices questionable insurance practices? Let me qualify that question. Let's say you perform scaling and root planing on an adult patient who has not brushed or flossed his teeth for 10 years. When the explanation of benefits (EOB) reaches your office, the insurance carrier informs you that its dental consultant disagrees with the diagnosis, and the claim is denied. I have seen several EOBs that go to the extent of telling the patient that he or she should speak to the dentist about the misdiagnosis. Furthermore, almost all EOBs provide no statement of correction or recourse—a simple denial is all you get. Many argue that the insurance carrier would rather have you perform a prophy instead of the more appropriate treatment of scaling and root planing. The key question here is, if you were to perform a prophy on this patient, would you be considered for malpractice? If the answer is yes, then why are insurance carriers not held to that same standard? Who polices these types of unfair, unethical, and often illegal practices? Allow me to spoil the ending—you can! Who are the Goliaths of your world? You may recall the stories of David and Goliath; the Spartan army, led by King Leonidas, at the Battle of Thermopylae; or my personal favorite, the Battle of Baltimore at Fort McHenry. On September 13, 1843, British warships delivered a downpour of rockets and mortar shells onto Fort McHenry in Baltimore Harbor. This relentless pounding of the American fort lasted 25 hours. Weeks prior to this attack, the British burned the Capitol, the Treasury, and the president's house. Needless to say, America's defenses were crushed and any hope of victory was shattered. Francis Scott Key, a 35-year-old American lawyer, witnessed the barrage of Fort McHenry from just eight miles away. "It seemed as though mother earth had opened and was vomiting shot and shell in a sheet of fire and brimstone," Key wrote. Given the magnitude of the attack, Key was certain of a landslide British victory. But in the "the dawn's early light," Key saw the American flag, not the Union Jack, waving bravely over the fort—the Americans had won. During the attack of Fort McHenry, Key penned a poem we now call "The Star-Spangled Banner." Many historians believe that Key's poem restored the confidence of those who were defending the "land of the free and the home of the brave," despite the scale of the attacks by British forces. Giving in is not an option Much like David, the Spartans, or the American soldiers defending Fort McHenry, we all have moments of doubt, fear, and uncertainty—especially when dealing with insurance carriers. Allow me to be the bearer of good news by informing you that you do not have to accept unethical or illegal decisions by insurance carriers. They hire licensed dental consultants and attorneys to advocate their own interests and often claim that you are contractually obligated to follow what they say. But if they were to tell you that you are contractually obligated to take a dive off of the George Washington Bridge every Saturday, would you do it? I didn't think so! Read full article on Dental Economics.
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