Health Care attorney, Daniel Schulte, discusses whether dentists are required to file claims with insurers in the latest issue of The Journal of The Michigan Dental Association (August 2021).
Question: I participate with several dental plans and insurers. They all require me to follow fee limitation, claim filing, and other contractual requirements. My understanding is that the claim-filing and other requirements apply even when the dental plan or insurer is not paying for my services – such as when patients have reached a limitation on benefits for the plan year, or when the dental plan or insurer says my treatment planning is not necessary or appropriate. But if a patient pays out of pocket and requests that I not file a claim with their dental plan or insurer, am I allowed to grant their request? Can I override my contractual agreements with dental plans and insurers?
Answer: The law that applies to this situation can be found in Section 17935 of the Health Information Technology for Economic and Clinical Health Act and 45 C.F.R § 164.522. These pertain to dentists and dental plans that are covered entities (which includes almost all dentists and dental plans).
When a covered dentist receives a patient’s request not to disclose the patient’s protected health information to a dental plan, he or she must honor that request if the following conditions are met:
- The disclosure to the dental plan would be for purposes of carrying out payment or health care operations.
- The disclosure is not one that is required by law.
- The protected health information pertains solely to dental services or items for which the dentist has been paid out of pocket, in full.
Before agreeing not to disclose this information, you should make sure the patient is aware of this law and its requirements and limitations. This could be done in a variety of ways, such as posting a notice in your office, giving patients the option when they check out, etc. The best practice would be to obtain the patient’s request for this restriction in writing. The request should be retained in the patient’s dental record. You should also document that the patient paid for the service out of pocket.
Read the complete Q&A in the Journal of the Michigan Dental Association on page 20.
About the author:
Daniel J. Schulte has more than 25 years of experience helping clients solve tough problems and capitalize on opportunities that require a blend of business and legal expertise. His practice focuses on addressing the legal, business, licensing, and regulatory challenges of health care professionals, organizations, and facilities. Dan understands how legal issues impact business objectives and, as a result, offers his clients practical, results-oriented advice. He is a Certified Public Accountant, former managing partner and current executive committee member of the firm. Dan also serves as co-chair of the firm’s Health Care Practice Group.
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