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United Concordia caps rates nationally for PPO

Dr. Clara Spatafore likes being able to treat the schoolteachers and police officers that seek endodontic care at her Sewickley Pennsylvania dental practice, despite receiving reduced reimbursements for the services she provides them.

"I feel I'm helping to do my part in the community by treating them," Dr. Spatafore explains. "The United Concordia PPO that covers these patients is the only PPO I belong to."

So she was shocked when her office manager, who is also her husband, told her the crux of a new UCCI contract provision means that Dr. Spatafore won't be able to charge her regular fees for services UCCI doesn't cover any portion of—even after a patient has reached his or her annual maximum.

"How will such a provision help anyone?" asked Dr. Spatafore, who is also the president-elect of the American Association of Endodontists. "I believe it's wrong on so many levels."

United Concordia Companies Inc. began sending out the contract amendment, its schedule of maximum allowable charges for noncovered services, explanatory letter and frequently asked questions to some 67,000 network dentists around the country in February. The last of the notices went out last month.

In describing how one portion of the amendment will affect patients in a dentist's practice, UCCI's FAQ states: "Patients will benefit from the opportunity to limit out-of-pocket expenses while following your recommendations, since your office will now accept United Concordia's Maximum Allowable Charge for services not covered by their benefit plan or in excess of their annual maximum. This may assist you in guiding patients through a lifetime of good oral health."

"Including a maximum allowable fee as part of the benefit or plan design allows patients access to services that otherwise may not be covered," Karen A Whitesel, UCCI's corporate vice president, professional relations, explained to ADA News. "Dentists can collect an agreed-upon fee and a patient is more likely to have the service done."

Dr. Spatafore doesn't see it that way. She thinks such a provision is more likely to create an access to care issue than diminish one.

"Dentists are already accepting close to 30 percent less than their normal fees," said Dr. Spatafore. "Helping people who are in need, giving to charity, I am all for it, do it all the time, I just want it to be my choice."

Jon Seltenheim, UCCI's senior vice president, customer service operations, said the schedule of maximum allowable charges for noncovered services by UCCI was reviewed by its national advisory counsel before it was released to all participating providers.

The national advisory counsel is comprised of 11 dentists, nine of whom are practicing and participate in UCCI preferred provider organization type plans around the country.

"Dentists who reviewed the list called the opportunity to participate attractive," said Mr. Seltenheim. Though not every service is included, the list includes most frequently noncovered services.

Mr. Seltenheim says the maximum allowable charge schedules are reviewed annually and although many schedules change, not all schedules change every year.

"By agreeing to these contract amendments we're agreeing to a fee schedule for our services that could easily be expanded to a national norm for dental fees for all patients," said Dr. James Hight, member of the Council on Dental Benefit Programs and chair of the Dental Benefit Information Service subcommittee.

A second change the amendment calls for will, as UCCI describes, "enable United Concordia to direct more patients into participating dental offices by allowing us to expand the number of groups utilizing our participating dentists."

UCCI's FAQs say if dentists don't sign the amendment they will be excluded from the opportunity to add additional patients should United Concordia partner with companies seeking to offer dental benefits under their name.

"I can only assume that they intend to lease out their network of providers to other insurance groups they enter into agreements with," said Dr. Hight. "This will require dentists to apply the UCCI fee schedule, discounts and caps on noncovered services to these new patients."

Noncovered services provisions began as a way to get services that have never been factored into the underwriting into the plans, particularly cosmetic services, according to Ms. Whitesel.

"Employers began requesting them because they wanted to provide broader services for their employees," Ms. Whitesel explains. "We started to do it to respond to market demand and to remain competitive."

A bone of contention between dentists and payers is that insurance companies claim they are regulated by state insurance commissioners and are exempt from federal anticompetitive actions for the "business of insurance" and that state legislative acts affecting insurance plans don't apply to their ERISA plans controlled by federal laws.

In June, Rhode Island passed a bill preventing dental plans there from capping the amount dentists can charge for services the plan doesn't cover. (The Employee Retirement Income Security Act of 1974 is a federal law that sets minimum standards for retirement and health benefit plans in private industry. Insurers that cover large employee groups who self-insure often have a greater percentage of members that fall under ERISA.)

The ADA Council on Government Affairs has drafted proposed federal legislation that would get directly at the issue for ERISA plans (federally regulated and self-insured plans), as state legislatures cannot make changes to ERISA.

"Antitrust and these insurance reforms are high priorities for the ADA and our legislative agenda, and our lobbyists are working on them now," said Dr. Joseph Crowley, CGA chair. "We remain hopeful that Congress will heed our concerns as they deal with health care reform."