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CDBP assists dentists with MetLife issue

May 20, 2013

By Kelly Soderlund, ADA News staff

Plaintiff: Dr. Richard Schainker contacted CDBP when he could not resolve an issue with MetLife earlier this year. The insurance company denied his claims, saying he did not have an active dental license.
The ADA Council on Dental Benefit Programs staff has taken several complaints in the past few months from dentists who submitted claims to MetLife only to have them denied because the company said the dentists did not hold active licenses.

But they did.

Dr. Richard Schainker, of St. Louis, said his license was set to expire Nov. 30, 2012.

He paid the fee and filled out the proper paperwork to renew his license a few days before it was set to lapse.

After submitting electronic claims to MetLife for procedures he performed on three children from the same family on Dec. 3, 2012, MetLife denied the claims, Dr. Schainker said. He and his patients received an explanation of benefits statement with a code that said, “Our records reflect that the provider was not authorized to perform the services on this date, therefore no benefits are available.”

Dr. Schainker's receptionist called MetLife and asked what the statement meant. The agent told her Dr. Schainker's license was expired.

MetLife continued to deny claims submitted by Dr. Schainker, but he had no issues with any other insurance company.

“My patients were equally confused since according to MetLife, I was practicing dentistry without a license,” Dr. Schainker said. “My main problem with MetLife was their agents stating to my patients that I wasn't authorized or legally allowed to practice dentistry.”

Dr. Schainker called Missouri's director of professional registration, who assured him his payment had been received and posted and that his license was active.

Upon further conversations with MetLife representatives, Dr. Schainker said he was told the company conducts random audits to check the status of dentists' licenses, and he was audited Oct. 29, 2012.

Upon inspecting Dr. Schainker's status, MetLife discovered his license was set to expire one month later.

Instead of checking back to see if Dr. Schainker allowed his license to lapse on Nov. 30, MetLife marked that it was expired.

After a lot of conversations and faxes, Dr. Schainker turned to the ADA for help. CDBP staff intervened and was able to persuade MetLife representatives to update Dr. Schainker's license status to active.

“The problem was that there was no way for us to resolve it,” Dr. Schainker said. “We did what we were supposed to and we couldn't talk to someone who could take care of it right away. It took weeks to get resolved.”

Dr. Mary Dooley, of Virginia Beach, Va., ran into the same situation. Electronic claims her office staff had submitted to MetLife were rejected.

“We immediately called all of our affected patients as they were getting this erroneous and ominous-sounding explanation on their explanation of benefits statements,” Dr. Dooley said. “Of course we stopped sending claims to MetLife and contacted them immediately. They stated that my license had expired, which it, in fact, did not.”

Dr. Dooley had a receipt showing she paid her licensing fee, which she faxed to MetLife as proof. The company told her the error would be corrected within a week. It wasn't and, again, it took an intervention from CDBP staff before MetLife corrected the problem.

“ADA staff promptly emailed an executive with MetLife and within a short period of time we were able to process claims,” Dr. Dooley said. “Many thanks to the ADA for solving this problem quickly so I could continue to do what I do best: dentistry.”

When asked for comment on Drs. Dooley and Schainker's complaints, MetLife provided the following statement:

“MetLife is committed to providing excellent service to dental providers. It is MetLife's policy to issue claims payment to doctors who are actively licensed to practice dentistry.

“Reports verifying the renewed license status for Dr. Schainker and Dr. Dooley were not received until after their previous license expiration dates and our other processes to verify their licensing did not capture their updated status. We are working to address their issues and have reviewed our internal processes to confirm providers' licensing.

“We are confident that our current process for verifying licenses should prevent similar occurrences in the future.”