Controversial review strategy called “practicing without a license’
UCCI Hit With Cease-Desist Order Over Out-of-State Review

New Mexico’s Board of Dental Health Care smacked United Concordia Companies Inc., Harrisburg, PA, on the wrist -- hard -- for using out-of-state dentists to review treatment there, saying it constitutes the practice of dentistry without a license. And, says the American Dental Association, UCCI may not be the last managed dental care plan to face a cease-and-desist order over the controversial practice. For its part, UCCI says it may respond in court.

The order cites a complaint filed with the Insurance Consumer Affairs Division of the New Mexico Public Regulation Department over UCCI’s claims evaluation practices. Specifically, the issue involves whether periodontal scaling and root planing or prophylaxis treatment was better for the patient in question. In the “offering of advice or authoritative comment regarding the appropriateness of dental therapies, the need for recommended treatment or the efficacy of specific treatment modalities for other than the purpose of consultation to another dentist,” the order says, the Pennsylvania-based UCCI consultant was in fact practicing dentistry without appropriate licensure.

The New Mexico Attorney General has gotten involved as well, pledging to enforce the cease-and-desist order. And the ADA has pledged its support to the AG. In a letter to the AG’s office, the ADA says the coverage denials by a dental consultant who doesn’t have a New Mexico license -- brought to its attention by a member dentist there -- “appears illegal.” The practice of using only in-state reviewers, the ADA says, “is critically important to protecting the public health and welfare.”

Peter Sfikas, chief legal counsel for the Chicago-based ADA, says that “the issue is whether the out-of-state dentist, by reviewing treatments done in, say, New Mexico, has a license there because he or she is considered to be practicing dentistry in that state. That’s why the AG there came down with that opinion.”

Tom Harbold, head of UCCI’s TRICARE program and utilization review manager for the company, says, on the one hand, that the order is no big deal and that his firm is working hard to comply. On the other hand, he adds, his firm might still sue. “In terms of the operational changes required by the order,” he says, “they’re very minor, so to speak, from our perspective.” The order, he concedes, “does create a little additional administrative cost, but overall I don’t think complying with the existing New Mexico requirements will have significant cost implications or problems for UCCI.”