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The Last Word: Drilling Down

Insurance companies are finally fighting back against exorbitant, seemingly unnecessary billings when a procedure could be done for a lot less.

March 7, 2012
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Related Topics: Top Stories - Frontpage, Health Care Costs, Health Care Benefits, Benefits
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I love my new dentist.

He never finds a cavity and offers sound, basic dental advice, urging me to use my electric toothbrush, floss daily and always use American Dental Association-approved toothpaste and mouthwash.

Much as my daily dental diligence is important, his skill, expertise and honesty have a lot to do with my cavityless grill. Like my mechanic, I put a lot of faith in my dentist. In fact, I am a firm believer that skilled, honest dentists, like a trustworthy mechanic, are worth their weight in gold.

That wasn't always the case with my oral history. Under a previous medical plan, I also had an excellent dentist. Upon changing plans, however, I embarked on an odyssey that led me through a series of dentists who tried to collect copayments when they weren't required, persist with treatments I didn't need and charge me for services beyond what I thought was a reasonable cost.

Quick example: I broke a molar. I called the latest in a frustrating series of in-network dentists, was seen that day and got the estimate. Besides the $1,400 my insurance was to be billed, I was told I would owe another $700-plus out-of-pocket.

Despite my sticker shock at the cost of a relatively routine dental procedure, I had the good sense to call my old dentist and tell him what the new dentist wanted to charge. The phone went silent on the other end. Finally he uttered, "For a crown?"

My old dentist offered to do the job for $698, out the door. No billing insurance; just cold, hard cash. I bit, if you will, at the offer.

While the emergency dental shopping adventure was frustrating enough, I was annoyed that my insurance company could have been billed for a procedure that ultimately was done for a lot less.

My old periodontal predicament came to mind recently as I read a story about one insurance company that has mapped out a comprehensive strategy to fight an overbilling practice with the relatively benign name of balance billing. Simply put, balance billing occurs when doctors bill patients for charges that exceed the amount payable under the insurance plan.

The innocuous-sounding accounting practice made headlines in February when insurance giant Aetna Inc. sued seven California surgery centers for treating patients at out-of-network rates, in one case charging $66,100 for a bunion repair. It was the latest lawsuit—Aetna also filed similar lawsuits last year in New Jersey, New York and Texas—in a strategic move by the insurer to fight what it perceives as abusive charges by providers.

Balance billing also has caught the attention of state regulators in New York. Officials there are asking health insurers for consumer complaints of price-gouging and unexpected bills after treatments performed by in-network physicians. They hope to draft legislation guaranteeing greater transparency about how charges are calculated and provide patients with a clearer idea of what they should pay.

The nationwide strategy is part of Aetna's assault on policymakers. Said Aetna's head of litigation, "This is a nationwide problem." Providers, he added, scheme to get around insurers' practices, and "you have patients getting bills crammed down their throats."

Amen to that. Insurance companies have some reckoning to do when it comes to billing transparency, but when an insurer is charged $66,000 by rogue doctors for bunion surgery, like patients, these mammoth companies have every right to cry foul.

Granted, the amount my former dentist wanted to bill my insurance company is small potatoes in the face of these outlandish costs. But the root of the problem is still the same.

And considering there's no menu posted on what to pay for a new crown or bunion removal, the consumer has the added burden of finding a cost-friendly alternative.

I say go get 'em, Aetna. And let's hope Cigna, Humana and other health insurers join in with a vengeance, jostling lawmakers for true health care cost transparency while simultaneously pressing medical providers to be honest with them and with their patients.

An honest dentist, just like a mechanic, shouldn't be the exception to the rule.

Rick Bell is managing editor of Workforce Management. To comment email editors@workforce.com.

Workforce Management, March 2012, p. 50 -- Subscribe Now!

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