- Email: [email protected]
Charges exceed maximum limit
jm LETTERS
A
TO THE E D I T O R
J A D A devotes this section to co m m en t by readers o n topics of cu rre n t interest to dentistry. T h e e ditor
reserves th e rig h t to edit a ll c o m m u n ic atio n s to fit available space a n d req u ires th a t all letters be typed, double-spaced, an d signed. N o m ore th a n ten references sh o u ld be given w ith each letter. P rin ted c o m m u n icatio n s do n o t necessarily reflect the o p in io n o r official policy o f the A ssociation. Y our p a rtic ip a tio n in this section is invited.
C harges exceed m a x im u m l i m i t . . . “ . . . In excess of m ax im u m eligible charge in accordance w ith the term s of the p la n . . . ” “ . . . Covered expense is the am o u n t allow able u nder the dental benefit p ro gram . . . ” “ . . . T h e charges subm itted exceed the reasonable and custom ary allow ance as determ ined b y . . . ” T h e fo llo w in g is excerpted fro m a letter w ritten by Dr. Sulliva n to the state attor ney, departm ent o f insurance, Tennessee, concerning som e o f the statem ents listed above. □ I w o uld like to b rin g your atten tio n to a problem concerning messages placed at the end of m any dental claim statem ents issued by insurance com panies. T h e problem is the inference my p a tients draw from these statem ents. T hey believe the insurance provider is im p ly in g my fees are too high. Of course, I believe this is n o t true; however, I can see how these statem ent messages are m is leading. First, is the reference to my “service.” N o one from any insurance com pany was present at the tim e the service was per form ed. I fin d it in a p p ro p ria te for a statem ent concerning policy coverage to refer to the service performed. Each patient 386 ■ JADA, Vol. 115, September 1987
is u n iq u e in his or her needs an d m ig h t require different procedures an d tim es to achieve the same results. T h a t is to say, service varies from p atien t to p a tie n t in time, difficulty, an d overhead. If the mes sage is descriptive of policy coverage an d the insurance com pany has n o know ledge of the service, then let it so state. I p ro pose a change from em phasizing “service” to “policy coverage.” T h e use of the words “exceeds” and “excessive,” especially in reference to my service, is a second m isdirection. It is my u n d e r s ta n d in g th a t in s u ra n c e U C R s (usual and custom ary rates) are derived from surveys an d analysis th a t yield some sort of m ean, average, or statistical norm . If this is true, then any p ractitioner ch arg ing above the U C R or some o th er a rb i trary p o in t is labeled as h av in g excessive fees. In p atien t understanding, this tran s lates to overcharging. It is u n fair to place this label because some dentists w ould always receive this b ran d in g independent of the fee range. In other words, if all fees were less than $1 an d averaged 50 cents, the 95-cent fee w ould trigger the message in question. I understand th a t som e m es sage m ust be issued w hen insurance cov erage is insufficient to m eet fees, b u t as before, let it say so. C h an g in g “exceeds” and “excessive” to “insufficient” w ith the em phasis on the coverage instead of the service seems more ap p ro p riate w ording. T h e w ord allow able is m isleading for
my patien ts as w ell w hen used in co n ju n c tio n w ith my service instead of their insurance coverage. T h e U CR is a fixed rate based on a fee range, n o t an allow able fee. It m ig h t be argued the in ten t is to refer to allow able coverage. B ut this is n o t the case w ith the messages addressing the professional service instead of the insurance coverage. V ariation in dental fees is necessary. Ju st as the am o u n t and terms of dental insurance coverage vary from one insurance com pany to another, so, too, professional fees vary from one dentist to another. Again, I say there is no “allow able” for service. T o clarify this, I suggest ch an g in g the term “allow able” to “ policy coverage lim it.” T hese messages have confused m any of my patients. I know other dentists w ho also have the same problem . O bviously these messages were poorly w ritten. I have w ritten w hat I believe to be a m ore p re cise and fair statem ent: “ Policy coverage lim it is insufficient to meet this fee.” R O B E R T R. SU L LIV A N , DDS H E N D E R S O N V IL L E , T N
□ C om m ent: Insurance com panies w rite directly to patien ts accusing th eir dentists of ch arg in g fees th a t are too high. T h e insurance com p an ies’ m ethodologies for calculating fees are proprietary so that w hen o u r mem bers are q u estioned by p atients ab o u t their fees, they have no way to refute the charge.
A
TO THE E D I T O R
J A D A devotes this section to co m m en t by readers o n topics of cu rre n t interest to dentistry. T h e e ditor
reserves th e rig h t to edit a ll c o m m u n ic atio n s to fit available space a n d req u ires th a t all letters be typed, double-spaced, an d signed. N o m ore th a n ten references sh o u ld be given w ith each letter. P rin ted c o m m u n icatio n s do n o t necessarily reflect the o p in io n o r official policy o f the A ssociation. Y our p a rtic ip a tio n in this section is invited.
C harges exceed m a x im u m l i m i t . . . “ . . . In excess of m ax im u m eligible charge in accordance w ith the term s of the p la n . . . ” “ . . . Covered expense is the am o u n t allow able u nder the dental benefit p ro gram . . . ” “ . . . T h e charges subm itted exceed the reasonable and custom ary allow ance as determ ined b y . . . ” T h e fo llo w in g is excerpted fro m a letter w ritten by Dr. Sulliva n to the state attor ney, departm ent o f insurance, Tennessee, concerning som e o f the statem ents listed above. □ I w o uld like to b rin g your atten tio n to a problem concerning messages placed at the end of m any dental claim statem ents issued by insurance com panies. T h e problem is the inference my p a tients draw from these statem ents. T hey believe the insurance provider is im p ly in g my fees are too high. Of course, I believe this is n o t true; however, I can see how these statem ent messages are m is leading. First, is the reference to my “service.” N o one from any insurance com pany was present at the tim e the service was per form ed. I fin d it in a p p ro p ria te for a statem ent concerning policy coverage to refer to the service performed. Each patient 386 ■ JADA, Vol. 115, September 1987
is u n iq u e in his or her needs an d m ig h t require different procedures an d tim es to achieve the same results. T h a t is to say, service varies from p atien t to p a tie n t in time, difficulty, an d overhead. If the mes sage is descriptive of policy coverage an d the insurance com pany has n o know ledge of the service, then let it so state. I p ro pose a change from em phasizing “service” to “policy coverage.” T h e use of the words “exceeds” and “excessive,” especially in reference to my service, is a second m isdirection. It is my u n d e r s ta n d in g th a t in s u ra n c e U C R s (usual and custom ary rates) are derived from surveys an d analysis th a t yield some sort of m ean, average, or statistical norm . If this is true, then any p ractitioner ch arg ing above the U C R or some o th er a rb i trary p o in t is labeled as h av in g excessive fees. In p atien t understanding, this tran s lates to overcharging. It is u n fair to place this label because some dentists w ould always receive this b ran d in g independent of the fee range. In other words, if all fees were less than $1 an d averaged 50 cents, the 95-cent fee w ould trigger the message in question. I understand th a t som e m es sage m ust be issued w hen insurance cov erage is insufficient to m eet fees, b u t as before, let it say so. C h an g in g “exceeds” and “excessive” to “insufficient” w ith the em phasis on the coverage instead of the service seems more ap p ro p riate w ording. T h e w ord allow able is m isleading for
my patien ts as w ell w hen used in co n ju n c tio n w ith my service instead of their insurance coverage. T h e U CR is a fixed rate based on a fee range, n o t an allow able fee. It m ig h t be argued the in ten t is to refer to allow able coverage. B ut this is n o t the case w ith the messages addressing the professional service instead of the insurance coverage. V ariation in dental fees is necessary. Ju st as the am o u n t and terms of dental insurance coverage vary from one insurance com pany to another, so, too, professional fees vary from one dentist to another. Again, I say there is no “allow able” for service. T o clarify this, I suggest ch an g in g the term “allow able” to “ policy coverage lim it.” T hese messages have confused m any of my patients. I know other dentists w ho also have the same problem . O bviously these messages were poorly w ritten. I have w ritten w hat I believe to be a m ore p re cise and fair statem ent: “ Policy coverage lim it is insufficient to meet this fee.” R O B E R T R. SU L LIV A N , DDS H E N D E R S O N V IL L E , T N
□ C om m ent: Insurance com panies w rite directly to patien ts accusing th eir dentists of ch arg in g fees th a t are too high. T h e insurance com p an ies’ m ethodologies for calculating fees are proprietary so that w hen o u r mem bers are q u estioned by p atients ab o u t their fees, they have no way to refute the charge.