Thursday Troubleshooter: Patient trying to call shots on how to file primary and secondary insurance

This dental front office manager has a patient trying to tell her how to handle primary and secondary insurance submissions. The patient may be asking for some unethical practices. What should the OM do?

Jul 19th, 2018
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Nearly everyone has problems and concerns on the job, and sometimes you're just too close to a situation to solve something yourself. Share your concerns with Team Troubleshooter, and the experts will examine the issues and provide guidance. Send questions to megk@pennwell.com.

QUESTION: Our patient came in with two insurances. Our office is not contracted with the primary plan but we are contracted with the secondary plan. The patient’s primary plan was going to be terminated within a couple weeks if his appointment. He didn't want us to send a claim to his secondary plan because he wanted to get one prophy out of the primary plan before it ended and then come in three months later to have cleaning number one with the secondary plan.

Keep in mind that both plans were new since the last time we saw him. I informed him we have to submit to both plans and he got upset because he wanted to use only the one plan and this would cause him to use up cleaning number one with the secondary and he didn't want to do that.

I have read some articles saying that due to HIPAA, a patient can ask us not to submit to insurance. Is this correct? I want to make sure that if this happens again I’ll know what to say. I was taught that we have to submit to both plans. Side note: every time this patient comes in he has new insurance, and he’s always trying to come in every three months for a cleaning. He has been to our office three or four times and has had new insurance every time. I feel like this could be a pattern so I want to be prepared for future occurrences. Thank you!

ANSWER: DIANNE GLASSCOE WATTERSON, RDH,Watterson Speaking and Consulting LLC, reached out to some members of the American Association of Dental Office Managers. Here’s what a few of them had to say:

#1: I've never heard this as a HIPAA provision. Since your office is contracted with the patient’s secondary insurance, there is usually a requirement that all billable expenses that can be covered by insurance must be sent on a claim. The only time it would not apply is if you do not charge the patient also.

We've also had some weird requests in our office, and most patients don't know how these things work. I had a patient ask to use his secondary insurance first, and we all know what will happen there. Overall, this is fraud. Don't be shy about using the term “fraud” with this patient and hopefully that will shut him down.

#2: I would say that because you are out of network, the whole balance is unlikely to be paid. That being said, if it were paid in full you would not need to send to the secondary (because you cannot collect more than your full fee). I would explain this to the patient. I would let him know that he has the right to refuse to use his secondary insurance, but he will likely have an out-of-pocket expense because you’re not an in-network provider.

#3: In my experience, if a patient does not want our practice to bill their insurance, they have that choice and they pay out of pocket. We do this frequently when we do flippers for patients. Some insurance companies consider flippers to be a removable device and will not pay for the implant or bridge due to a frequency and replacement clause. So, in order not risk it, we inform patients about this and they pay out of pocket for the flipper and we do not file the insurance.

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