Do you submit your fees and have them approved by an “insurance company”? If you live in California or Michigan, one of these insurance companies (PPOs) recently told you that they are now paying with the 80th perzentile rate, not with the 90th? Did you join an innocent PPO without knowing it? Does this PPO have a “Hold Harmless” clause in the contract? Could you put your license to practice dentistry on your answer? You`d stop what you`re doing and find out if you think you could be sued successfully because of the language of the contract, right? Under a Hold Harmless clause, the doctor may take additional responsibility for any administrative decision of the client that results in an unfavourable result for the patient. Are you already changing your treatment due to refund restrictions in the contract? Who is held responsible in court, you or she? You are responsible for contractual languages that you have probably never seen or read! Alabama recently tried to stem managed care`s intervention. They discovered that new laws in Alabama are anticipated by ERISA (Employment Retirement Income Security Act-1974), a law that set standards for health care programs, including dental insurance. In addition, the courts have informed the state that the laws do not apply to Blue Cross/Blue Shield of Alabama because it is not an “insurance company.” The second part of his response included the legal fact that HMO had a “Hold Harmless” clause in the contract. In secular terminology, this means that the contract states that the physician and patient release the HMO from liability for an “undesirable” outcome as a result of OMH policy. This is a deferral of liability in which the doctor agrees to keep the client free of any debt that may result from the contractual agreement. The author practices in St. George, UT, and is a well-known advisor and lecturer in dental insurance, case acceptance and profitability. You may be a PPO or HMO provider and you don`t even know it. If you`ve signed an agreement with what you think is an “insurance company” and that agreement puts your name on a list of suppliers, then you`re probably a preferred supplier. The acronym for an organization with a preferred supplier would be “PPO,” right? Note that contractual constraints do not change standards of care.
Physicians should remember that their standard of care – that is, the standard by which they could be found negligent – does not change anything about whether or not a contract is signed. You have reduced your fees or accepted them less by contract to be a preferred supplier. The quality of care for these patients must be the same as for a fee-for-service patient. The level of reimbursement is significantly reduced, but the level of care is the same. Does this seem useful to you? The New York Times recently reported that there is a national trend that shows a reduction in care when the patient participates in a plan offering the doctor reduced reimbursement. That`s not surprising to anyone, is it? Your state council may withdraw your license to care below the standard in your state. So you accept less money, the patient complains, and you suffer from the headaches and grief of an on-board inspection. Stop now and think again. Are you sure of the agreements you have made? Could that play a role? Are you really too busy to know? How busy will you be after your license suspension? What if the patient didn`t pay you? What if the HMO or PPO goes off the rails? If they go bankrupt, do it too. .