A Typical Letter Downloaded from the Dentists' Managed Care
Discussion Group on the Internet
Date: Mon, 26 May 1997
11:28:05 -0400 (EDT)
From: DrSmard@aol.com
Subject: TRUE STORY!
Attn: Managed-care Digest Participants
I have a story for you guys! It's a sad but true story. And for
any of the CEOs of managed-care companies reading this, I'd like
for YOU to address this story! In fact, I'll send you a copy to
make sure you see this. Last Friday, May 22nd, a seven-year-old little girl, Tiffany, came
into our office for an exam and cleaning. It was the first time
we've seen Tiffany since she was three-years-old. Her father is
the sole provider for the family, which consists of his wife and
three little girls. This family is a product of an economy that
doesn't give a financial break to families who choose to work where
only the basic essentials are afforded. The mother doesn't work
because she's home raising her children, and, even if she wanted
to work, the cost of day care would offset any income she is capable
of receiving. They truly do qualify for welfare, but being the proud
father he is, they desperately try to fend for themselves. I'm telling you their history so that you'll understand why it
has been so long since we've last seen the family members in our
office. The father became eligible for dental insurance on April
1, 1997; at which time he enrolled in the plan that was best "sugarcoated. " Like most people, this man is uninformed about health insurance
and how it works, and he thought he'd, at least, have a supplement
to help him to pay for any dental work needed. His company takes
a premium out of his paycheck every month and, in turn, he SHOULD
have a dental benefit. . . .Right? WRONG!!!! You see, he chose the
HMO plan because he was told it was the better plan. What he didn't
realize was that he'd have to see a doctor chosen for him by the
insurance company. This ONE doctor, the only one on the plan, isn't
even taking new patients. And because he didn't verbally say, "I
choose this doctor" he literally did not have any benefits. (Note
of concern: If there is only one doctor on the plan, why did he
have to SAY he chose that doctor?
It should be understood. ) This means he's paying for a benefit
he CAN'T USE!
Anyway, not knowing how his insurance works, he called me to set
up an appointment for his little girl because she woke up the night
before with a "toothache. " I scheduled Tiffany to come in immediately. In the meantime, we called his insurance to verify benefits so I
could prepare him for his out-of-pocket expense. When I was told
he was on the DMO plan for Prudential I immediately called him back
and explained that he'd have to see another doctor if he wanted
to use his insurance. I also told him he'd have no co-payment if
he saw this other dentist. He told me he wanted our office to see
Tiffany and was prepared to pay for it with no help from his insurance. The examination presented a diagnosis of rampant caries. Due to
the extensive work needed, the emergency situation, and the desire
to make the upcoming event a non-traumatic one for the child, we
recommended that she be referred to a pedodontist. We felt this
was in the best interest and care of the child and followed our
standard operating procedures. The sad look on the face of this
father was heartbreaking. He was so sorry the situation was so extreme. All he wanted was the best "his money could buy" for his little
girl. The horrible part of it was that "his money" couldn't afford
for it to be all OUT-OF-POCKET. (That's why he bought dental insurance. )
We proceeded by calling Prudential to find out the steps needed
to get Tiffany properly referred. We were told that she needed to
be referred by a preferred provider in order to receive benefits. The drawback was that the only ONE on the plan had CLOSED ENROLLMENT. There were no specialists on their list either, so what difference
did it make WHO referred them. Good point, but one more drawback. . .the age limit for referrals to a pedodontist is six. . .No Exceptions!
WHO WROTE THESE RULES???????????????
After approximately 45 minutes on the phone with Prudential, we
were referred to the provider relations hotline. But before they
did that, the representative for Prudential told me, and I quote,
"If you really want to help these people that badly, you could sign
up and become a provider. " Can you believe this? I just told him
we could not treat this child. . .that she needed to see a pedodontist. . .which they would not approve. . .and he's trying to make a sale!?!
Needless to say, I blew up and told him that we were providers for
Prudential years ago and we dropped the plan because of the Idiotic
Rules they had and Still Have!
I then called the provider hotline and, finally, got some results. This department managed to make amends for the screw up concerning
the fact that this family has paid for benefits they could never
receive. So they authorized an out-of-network visit for the exam. However, they still would NOT approve the referral to a pedodontist. Nor would the doctor THEY signed up, see Tiffany. Doesn't this indicate
that Prudential might be putting the interest of their company over
the health of a child?
One of the main arguments against managed-care is that the dentists
are put in unethical positions of not being able to provide the
best possible care with the income they are ALLOWED; what about
the ETHICS of the INSURANCE COMPANY?
My questions to all of you are:
1. Can they do this and get away with it?
2. WHY would they do this?
3. What can we do about it?
Dena Simard, CPM
cc: Louisiana State Commissioner of Insurance, Jim Brown
Prudential DMO
The Profitable Dentist, publication
LDA
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