Health Care attorney, Daniel Schulte, answers questions regarding what to do when dissatisfied with a carrier’s reduction or denial of a workers’ compensation claim. The Q&A can be found in the Journal of Michigan Dental Association (February 2020) –
Question: A year or so ago, a patient came to see me who needed dental work due to an injury suffered on the job. I held off doing crowns because I believed endodontic treatment was going to be necessary. I did composites and accepted what his employer’s workers’ compensation insurer paid. Now, the patient and returned, needing the root canal treatment and crown as a result of the original trauma. However, the workers’ compensation carrier refuses to pay for the needed endodontic therapy and a restorative core and crown, stating it already covered the care needed at the time of the injury. Is there a mechanism to appeal this decision?
The best practice when electing a conservative treatment option initially is to inform the patient and the insurance carrier that the claim should be kept open. This is due to the likelihood a root canal and crown may be needed in the future. This should also be clearly documented in the dental record.
Michigan’s Workers’ Disability Compensation Act covers dental services required to correct the effects of a work-related injury. A dentist billing a carrier (e.g., an insurer, self-insured employer, or a fund referenced in the act) for a covered service must accept the maximum allowable payment (“MAP”) amount as payment in full. It is not permitted to balance-bill the patient. This means you cannot bill the patient for the amount disputed by a carrier. You also cannot bill the patient for the amount that your customary fee exceeds the MAP. When a dentist’s charge is less than the MAP, or if a dentist has a contract with a carrier to a lesser fee, payment is made at the lower amount. Most MAP amounts are pre-determined fixed fees, although some dental procedures do not have pre-calculated fees.
If it is ultimately determined that a patient did not suffer a work-related injury, a dentist may bill the patient or the patient’s insurer for the dentist’s customary fee, absent a different fee arrangement with the patient or insurer.
When a dentist is dissatisfied with a carrier’s reduction or denial of a claim, the dentist may submit to the carrier a written request for reconsideration within 60 days after receiving notice of an adjusted or rejected claim. A dentist may not dispute a payment simply because of dissatisfaction with a MAP amount. The carrier must re-evaluate the original claim and accompanying documentation and respond within 30 days. The carrier must notify the dentist and explain the reasons for its decision. They must cite the specific policy or rule supporting the adjustment or rejection.
Read the complete answer in Journal of the Michigan Dental Association on page 20.
About the author:
Daniel 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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