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What are the Ethical Considerations in Accepting Lower Reimbursement?
PERSPECTIVES
ETHICAL
MOMENT
ETHICALMOMENT WHAT ARE THE ETHICAL CONSIDERATIONS IN ACCEPTING LOWER REIMBURSEMENT?
Q
One of my state’s largest dental insurance carriers has substantially cut its reimbursement rates to its members. We have filed fees with them, and I am concerned about a financial incentive to alter my treatment recommendations when my reimbursement rate is cut. A majority of my patients have plans with the carrier, and I am wondering how I can work things out and still be ethical. I always have kept one fee schedule for all of my patients, regardless of their dental plan. What should I do?
A
Having recently gone through that process, I understand many of the issues you are facing. I know that many dentists try to keep their full fees the same as their filed fees, not wanting to have a twotiered fee schedule. Other dentists have found that, as their full fees increased to reflect an increase in expenses, their filed fee increases were limited by contract and, over time, there was a difference in fees. Dentists who are members of any insurance company’s preferred provider organization panel likely are used to accepting a reduced fee compared with their full fee, with the idea that they have the opportunity to attract more patients to the practice and make up the difference in reduced fees with an increased number of patients. In effect, dentists may charge more than one fee for a given procedure based on their contracts with insurance companies. The American Dental Association Principles of Ethics and Code of Professional Conduct1 (ADA Code) addresses this situation specifically in Section 5.B.3, Fee Differential. The fee for a patient without dental benefits shall be considered a dentist’s full fee. This is the fee that should be represented to all benefit carriers regardless of any negotiated fee discount. Payments accepted by a dentist under a governmen-
310
JADA 144(3)
http://jada.ada.org
tally funded program, a component or constituent dental society–sponsored access program, or a participating agreement entered into under a program with a third party shall not be considered or construed as evidence of overbilling in determining whether a charge to a patient, or to another third party in behalf of a patient not covered under any of the aforecited programs constitutes overbilling under this section of the Code.1
According to Section 5.B.3, “[a] full fee is the fee for a service that is set by the dentist, which reflects the costs of providing the procedure and the value of the dentist’s professional judgment.”1 Whenever submitting a claim for treatment, you should use your full fee and then adjust it accordingly. Any time there is more than one fee schedule (the dentist’s full fee and any contracted benefit plan’s fee), a concern arises that patients may be treated differently on the basis of their reimbursement level. Is less time spent with a patient for whom the fee paid is lower? Are fewer choices offered because the profit margin is too low? Three primary areas of the ADA Code are applicable here: Section 1.A, Patient Involvement, states that the dentist “should inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions.”1 Section 4, Principle of Justice (“fairness”), states that the “dentist has a duty to treat people fairly. This principle expresses the concept that professionals have a duty to be fair in their dealings with patients, colleagues and society. Under this principle, the dentist’s primary obligations include dealing with people justly and delivering dental care without prejudice.”1 Section 3, Principle of Beneficence (“do good”), states that the “dentist has a duty to promote the patient’s welfare.”1 The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires and values of the patient. The same ethical considerations apply whether the dentist engages in fee-for-service,
March 2013
Copyright © 2013 American Dental Association. All rights reserved.
PERSPECTIVES
managed care or some other practice arrangement. Dentists may choose to enter into contracts governing the provision of care to a group of patients; however, contract obligations do not excuse dentists from their ethical duty to put the patient’s welfare first.1
When you are confronted with decisions regarding provider contracts, there are many ethical questions you should consider. If your reimbursement for a procedure is less than what you typically charge, will you still offer the patient this treatment option and provide the patient with all reasonable alternatives? For example, if you typically use a gold onlay in a certain situation and the reimbursement is better for an all-ceramic crown, will you offer the option of a gold onlay to this patient? Must you do so to comply with Section 1, Principle of Patient Autonomy (“self-governance”),1 which embodies informed consent? If you decide to use a laboratory that costs less than the laboratory you currently use, will you use it for all of your patients or only for those patients for whom the reimbursement is lower? If you decide to use an offshore laboratory to reduce overhead, will you discuss this with your patients? These are just some of the questions you should be asking yourself when dealing with insurance contracts. If you choose not to offer a treatment option to a patient strictly on the basis of his or her dental benefit plan, you are limiting patient involvement in the treatment plan and could be violating Section 1.A above. In the above example involving placement of a gold onlay versus an all-ceramic crown, Section 2, Principle of Nonmaleficience (“do no harm”), also may come into play. “The dentist has a duty to refrain from harming the patient.”1 Is there potential harm to the tooth in removing more tooth structure to place a
ETHICAL
MOMENT
crown when an onlay is indicated? When considering provider contracts, you may want to take advantage of an important member benefit: the ADA Contract Analysis Service. This service provides members with a clear, plain-language explanation of contract terms and is designed to allow dentists to make informed and independent decisions on the merits of provider contracts. If you feel that a third-party contract prevents you from caring for your patients fairly or limits your ability to treat them in the same way you treat your other patients, you may want to consider opting out of the contract. The ethical bottom line is that all patients should be offered the same treatment options and given the same quality of care, regardless of the level of reimbursement. ■ Rod B. Wentworth, DDS, practices general dentistry in Bellevue, Wash., and is a past chair of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Ethical Moment is prepared by individual members of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (CEBJA), in cooperation with The Journal of the American Dental Association. Its purpose is to promote awareness of the American Dental Association Principles of Ethics and Code of Professional Conduct. Readers are invited to submit questions to CEBJA at 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail “[email protected]”. The views expressed are those of the author and do not necessarily reflect the opinions of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs or official policy of the ADA. Address reprint requests to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E. Chicago Ave., Chicago, Ill. 60611. 1. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. “www.ada.org/sections/ about/pdfs/ada_code.pdf”. Accessed Jan. 21, 2013.
JADA 144(3)
http://jada.ada.org
Copyright © 2013 American Dental Association. All rights reserved.
March 2013 311
ETHICAL
MOMENT
ETHICALMOMENT WHAT ARE THE ETHICAL CONSIDERATIONS IN ACCEPTING LOWER REIMBURSEMENT?
Q
One of my state’s largest dental insurance carriers has substantially cut its reimbursement rates to its members. We have filed fees with them, and I am concerned about a financial incentive to alter my treatment recommendations when my reimbursement rate is cut. A majority of my patients have plans with the carrier, and I am wondering how I can work things out and still be ethical. I always have kept one fee schedule for all of my patients, regardless of their dental plan. What should I do?
A
Having recently gone through that process, I understand many of the issues you are facing. I know that many dentists try to keep their full fees the same as their filed fees, not wanting to have a twotiered fee schedule. Other dentists have found that, as their full fees increased to reflect an increase in expenses, their filed fee increases were limited by contract and, over time, there was a difference in fees. Dentists who are members of any insurance company’s preferred provider organization panel likely are used to accepting a reduced fee compared with their full fee, with the idea that they have the opportunity to attract more patients to the practice and make up the difference in reduced fees with an increased number of patients. In effect, dentists may charge more than one fee for a given procedure based on their contracts with insurance companies. The American Dental Association Principles of Ethics and Code of Professional Conduct1 (ADA Code) addresses this situation specifically in Section 5.B.3, Fee Differential. The fee for a patient without dental benefits shall be considered a dentist’s full fee. This is the fee that should be represented to all benefit carriers regardless of any negotiated fee discount. Payments accepted by a dentist under a governmen-
310
JADA 144(3)
http://jada.ada.org
tally funded program, a component or constituent dental society–sponsored access program, or a participating agreement entered into under a program with a third party shall not be considered or construed as evidence of overbilling in determining whether a charge to a patient, or to another third party in behalf of a patient not covered under any of the aforecited programs constitutes overbilling under this section of the Code.1
According to Section 5.B.3, “[a] full fee is the fee for a service that is set by the dentist, which reflects the costs of providing the procedure and the value of the dentist’s professional judgment.”1 Whenever submitting a claim for treatment, you should use your full fee and then adjust it accordingly. Any time there is more than one fee schedule (the dentist’s full fee and any contracted benefit plan’s fee), a concern arises that patients may be treated differently on the basis of their reimbursement level. Is less time spent with a patient for whom the fee paid is lower? Are fewer choices offered because the profit margin is too low? Three primary areas of the ADA Code are applicable here: Section 1.A, Patient Involvement, states that the dentist “should inform the patient of the proposed treatment, and any reasonable alternatives, in a manner that allows the patient to become involved in treatment decisions.”1 Section 4, Principle of Justice (“fairness”), states that the “dentist has a duty to treat people fairly. This principle expresses the concept that professionals have a duty to be fair in their dealings with patients, colleagues and society. Under this principle, the dentist’s primary obligations include dealing with people justly and delivering dental care without prejudice.”1 Section 3, Principle of Beneficence (“do good”), states that the “dentist has a duty to promote the patient’s welfare.”1 The most important aspect of this obligation is the competent and timely delivery of dental care within the bounds of clinical circumstances presented by the patient, with due consideration being given to the needs, desires and values of the patient. The same ethical considerations apply whether the dentist engages in fee-for-service,
March 2013
Copyright © 2013 American Dental Association. All rights reserved.
PERSPECTIVES
managed care or some other practice arrangement. Dentists may choose to enter into contracts governing the provision of care to a group of patients; however, contract obligations do not excuse dentists from their ethical duty to put the patient’s welfare first.1
When you are confronted with decisions regarding provider contracts, there are many ethical questions you should consider. If your reimbursement for a procedure is less than what you typically charge, will you still offer the patient this treatment option and provide the patient with all reasonable alternatives? For example, if you typically use a gold onlay in a certain situation and the reimbursement is better for an all-ceramic crown, will you offer the option of a gold onlay to this patient? Must you do so to comply with Section 1, Principle of Patient Autonomy (“self-governance”),1 which embodies informed consent? If you decide to use a laboratory that costs less than the laboratory you currently use, will you use it for all of your patients or only for those patients for whom the reimbursement is lower? If you decide to use an offshore laboratory to reduce overhead, will you discuss this with your patients? These are just some of the questions you should be asking yourself when dealing with insurance contracts. If you choose not to offer a treatment option to a patient strictly on the basis of his or her dental benefit plan, you are limiting patient involvement in the treatment plan and could be violating Section 1.A above. In the above example involving placement of a gold onlay versus an all-ceramic crown, Section 2, Principle of Nonmaleficience (“do no harm”), also may come into play. “The dentist has a duty to refrain from harming the patient.”1 Is there potential harm to the tooth in removing more tooth structure to place a
ETHICAL
MOMENT
crown when an onlay is indicated? When considering provider contracts, you may want to take advantage of an important member benefit: the ADA Contract Analysis Service. This service provides members with a clear, plain-language explanation of contract terms and is designed to allow dentists to make informed and independent decisions on the merits of provider contracts. If you feel that a third-party contract prevents you from caring for your patients fairly or limits your ability to treat them in the same way you treat your other patients, you may want to consider opting out of the contract. The ethical bottom line is that all patients should be offered the same treatment options and given the same quality of care, regardless of the level of reimbursement. ■ Rod B. Wentworth, DDS, practices general dentistry in Bellevue, Wash., and is a past chair of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs. Ethical Moment is prepared by individual members of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs (CEBJA), in cooperation with The Journal of the American Dental Association. Its purpose is to promote awareness of the American Dental Association Principles of Ethics and Code of Professional Conduct. Readers are invited to submit questions to CEBJA at 211 E. Chicago Ave., Chicago, Ill. 60611, e-mail “[email protected]”. The views expressed are those of the author and do not necessarily reflect the opinions of the American Dental Association Council on Ethics, Bylaws and Judicial Affairs or official policy of the ADA. Address reprint requests to the American Dental Association Council on Ethics, Bylaws and Judicial Affairs, 211 E. Chicago Ave., Chicago, Ill. 60611. 1. American Dental Association. American Dental Association principles of ethics and code of professional conduct, with official advisory opinions revised to April 2012. “www.ada.org/sections/ about/pdfs/ada_code.pdf”. Accessed Jan. 21, 2013.
JADA 144(3)
http://jada.ada.org
Copyright © 2013 American Dental Association. All rights reserved.
March 2013 311