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32241 Crown Valley Parkway #200
Dana Point, CA 92629 | Directions

ETHICS COMMITTEE

Insurance Co-Payments
We all know that forgiveness of the co-payment and/or deductible is both illegal and unethical. However, it still continues to be a nasty habit that some dental offices practice as part of their financial arrangements with their patients. Perhaps a closer look at the problem may prove useful.

Why do insurance companies require the payment of co-payments and deductibles in the traditional insurance plan? I'm sure we all know that insurance companies use complex statistical analysis and actuarial tables to pencil out the financial viability of providing a benefit to a particular individual or group. Some of the parameters used in defining their formulas are exclusions, maximum benefits, and deductibles. The co-payment is especially important in dental insurance as this shifts an important responsibility onto the patient in seeking dental treatment. If the patient was not obliged to make a co-payment, then the frequency of use would obviously increase. Therefore, one of two scenarios would have to exist. Either the insurance premiums would have to dramatically increase, which would probably make dental insurance benefits prohibitive as an employee benefit, or the dental fee schedules would have to be adjusted to accommodate the increased use of the benefit. This is obviously a simplified but realistic version of how insurance companies MANAGE CARE; get it! In the aforementioned scheme, by forgiving the co-payment we shift that portion of the responsibility from the patient back to the provider by decreasing his/her fees. But of course, we as providers make up this loss by increasing our volume of service-NOT! This is what insurance companies would like us to believe in managing dental care. What do insurance companies/entities know about dentistry? Let me restate that question. What do insurance companies know about money and finance? HINT #1: Declared Assets have many zeros. HINT #2: What companies typically own skyscrapers? Answer at bottom of page. Has anybody noticed that dental insurance maximum benefits have remained at around $1000.00/year since the 1960's? Since I'm not a mathematician, I'll need some help on this one to figure out all the ramifications.

As a profession, we need to keep the patient involved and responsible for their dental care. By forgiving the co-payment, we are not only systematically factoring the patient's financial responsibility out of the treatment, but also their responsibility for their own health, since it becomes free. Although I do not have a Ph.D. in philosophy, I feel fairly confident in saying that by nature in life, there is typically a lack of appreciation for things that come too easy or are not earned. Remember an unpaid bridge or denture never fits quite right in the eyes of the patient. The irony is that with those same patients that received that bridge or denture in one of those capitation plans (no co-payment) the former statement often times happens to be true, (literally).

We ought to provide our patients the services that they need and deserve, unencumbered by what insurance companies tell us we should do; we should also get fairly paid for these services (and I'm not being sarcastic). This requires us to educate our patients about their needs, not the insurance company's needs. As William G. Dickerson, DDS, in a periodical stated, "We have been too reluctant to recommend what is necessary since insurance won't pay for it. It is a crime that 85 percent of adult Americans have periodontal disease, yet we let insurance companies dictate inferior and ineffective treatment. If you had cancer and you required six chemotherapy treatments, you wouldn't do just two if that was all insurance paid for, would you? But we have under-treated periodontal disease for years because we have been too reluctant to recommend what is necessary since insurance won't pay for it."

One last bit of information regarding a more recent insurance company financial strategy in their quest to win the insurance game that was published in the MCDS Oral Report. "Hopefully you are aware of a ploy by dental insurance companies that would seem to be an attempt to confuse, if not trick, patients into thinking that they have more of a benefit than they really do. The phrase, "non-duplication of benefits" is now often included in the policy, thrown in with all the other line print, and not highlighted or delineated in any particular way. It therefore becomes a contractual agreement that states words to the effect that when the insurance company is the secondary carrier in a dual-coverage situation, their obligation in paying benefits is diminished by what the primary carrier pays. This is a drastic change from the traditional way that dual coverage has been paid off. If not fraudulent in intent, for an insurance company to say they will pay "X" amount of dollars on the pre-authorization, knowing they won't"

In summary, let's not bring ourselves down to the level of insurance companies with their bag of dirty tricks in playing this game. So please do yourself a favor and collect all your co-payments. It's owed to you and the patient will be better off in the long run. We, in the ethics committee look forward to your response, comments, and editorials.

Answer: Lots (and I don't mean parcel).

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