DeLayne Lefevre has two dental offices serving thousands of patients in Madison and Delaware counties. Her patient, whom she called Jim, needed dentures and extractions, but the specific assignment of benefits (AOB) with his insurance company did not allow immediate payment to Lefevre.
“I agreed to let Jim pay once his insurance company sent him the check. A few months went by without any payment, so my team called the insurance company and asked where the payment was. They said they had already processed that claim and sent the check to Jim,” Lefebvre said before the Senate health committee on Wednesday.
But when Lefebvre called Jim, he had already spent the money thinking it was an insurance refund check.
“Jim says … ‘I don’t have the money to pay you, Dr. Lefebvre, but I sure like my teeth,'” Lefebvre recalled. “So he got the teeth, he did the exports, and I never got paid for it.”
In another type of clinic, a patient’s insurance may pay the bill directly. But dentists and insurers have a different relationship. Because of this, dentists say many patients simply walk out of their offices without paying, or they get a check from their insurance and spend it without knowing it’s meant for their dental care.
Senate Bill 132 seeks to fix that by adding some additional regulations for insurers and, particularly for Lefevre and others, allowing patients to assign benefits to dental providers regardless of whether their dentist is in-network or not.
The overall measure — authored by Sen. Liz Brown, R-Fort Wayne — also includes requirements for the Family and Human Services Administration to develop Managed Care for Long-Term Supports and Services, amends telemedicine law, facilitates licensing for foreign-born nurses, eliminates certain requirements for health facility administrators, and more.
Dental provisions are controversial
Lefevre, speaking as part of a group from the Indiana Dental Association that sponsored the bill, said she now collects up front for new patients or those whose out-of-network insurance policies mimic Jim’s policies with an AOB that does not transfer rights and benefits to a third party such as Lefevre.
Dentists and state regulators disagree about compliance fund spending
“People hate going to the dentist. they’re scared, they’re anxious for whatever reason … now imagine what they have to go through to now switch providers because their insurance carrier won’t pay us as dentists,” Lefevre said. “The added stress to that — they may choose not to go to the dentist — … that’s a loss of continuity of care.”
But not everyone agreed, including one of the state’s largest nonprofit dental insurance providers: Delta Dental of Indiana, which has a participation agreement with about 80 percent of the state’s dentists.
Dentist Jeff Johnston — Delta’s senior vice president and chief scientist for Michigan, Ohio and Indiana — noted key differences between in-network and out-of-network dentists, including requiring free replacements for improperly placed crowns.
“Insurance companies require dentists to meet certain credentialing standards, adhere to claims-handling policies and adhere to quality-of-care standards … (which) offer significant cost and treatment guarantees for patients,” Johnston said. “We’re confident that (AOBs) will outperform smaller networks (and) create an incentive for dentists to leave an insurance network because they’re getting paid directly.”
“Dentists can and will charge higher fees to avoid insurance costs and quality protection. In other words, patients will end up paying more and getting less,” he continued.
Johnston said Indiana allowed AOBs in 2008 and subsequent efforts to amend the dental insurance process resulted in one change: a requirement for insurers to specify whether the payment is for dentists rather than the patient.
He got the teeth, he did the exports and I never got paid for it.
– Dr. DeLayne Lefevre, a dentist in Madison and Delware counties;
“As far as the General Assembly has gone in the past, I think, because of concerns about the protections that will be lost for patients,” Johnston said.
Delta’s testimony was echoed by the Insurance Institute of Indiana, which said insurers would also be adversely affected as providers were abandoned — a cost they argued would be passed on to consumers — as well as the Indiana Chamber of Commerce, which called the AOB “billing and collection issue between doctor and patient”.
Brown pushed back, saying she had incorporated Delta’s earlier concerns into the bill and required insurers to pay dentists directly — even if that meant a reduced amount for out-of-network providers.
“If the Delta Dental product and being in-network is as seamless and as easy and competitive, then there should be no change. But we’re giving patients more power and more choice,” Brown said. “I asked for this information … (to) prove to me, to other states, that the network (participation) will be discontinued.
“… I never received that information.”
Language for long-term care, nurses
Another part of the bill includes payment deadline requirements for the Family and Human Services Administration when it comes out with a new managed care plan for long-term care, also known as Pathways to Aging.
Hoods in nursing and assisted living homes, or those who use home and community services, are the last population not subject to a managed care plan, which is set to roll out this summer. Brown said this bill does not jeopardize or slow traffic, but that other states moving to such plans have reported late payments to providers.
The managed care transition will begin in July 2024
Managed care is a health care service delivery model in which a key entity manages every aspect of care for a consumer for a fixed, upfront amount per person, rather than individual providers billing the government piecemeal for each service, also known as a fee- for service.
Brown, in her introduction, recalled a failed care management rollout by the FSSA in relation to the transfer. He stressed that while the FSSA had not yet done anything wrong, it was a precautionary measure against late payments.
“We’re talking about nursing homes and assisted living people — our most vulnerable population,” Brown said. “This is not meant to be punitive.”
The FSSA did not testify on the bill, although Brown acknowledged that agency officials have concerns.
The Indiana Health Care Association (IHCA) and Leading Age Indiana, which represents nursing home and assisted living operators, have previously expressed reservations about managed care and supported the bill’s new protections.
Nick Goodwin, director of government affairs for the IHCA, said his organization wanted to ensure a “continuum of care”.
“Thirteen states have implemented a mandatory comprehensive statewide managed care program similar to what Indiana is trying to do, and another 15 have a mix,” Goodwin said. “We looked at these states and many of my members are multi-state agencies (that) have gone through this transition and they said the payment interruptions were the most concerning aspect.”
GET MORNING HEADLINES DELIVERED TO YOUR INBOX
