Legislative Chair Dr. Scott Morrison and I attend the ADA Lobbyist Conference every year in December. In 2009, we learned of insurance companies instituting “non-covered services” policies. In 2010, the NDA introduced legislation prohibiting the non-covered services policies. We are currently in litigation with the Nebraska Department of Insurance over interpretation of our statutory changes.
At the 2019 Lobbyist Conference, we learned of two new insurance tactics disadvantaging dentist providers and introduced two bills to address those issues.
Virtual Credit Cards
We would like to thank Senator Lindstrom for introducing
LB 954 on behalf of the NDA, addressing Virtual Credit Cards and Network Leasing. Some dental plans are paying the claim with a virtual credit card that must be redeemed by the dental office.
The problem??
The dental office takes another 2-4% reduction on the payment due to the electric transaction cost, after already agreeing to a reduction in the fee schedule. Those extra costs don’t disappear. They have to be accounted for somewhere, often in higher fees for private paying patients. LB 954 does not say that insurance companies cannot make a payment with a virtual credit card . . . LB 954 just says that this form of payment cannot be the only form of payment.
Silent Network Leasing
This happens when the dental plan leases its Network Provider List to another dental plan without the knowledge and consent of the dentist. A patient shows up in the dental office with, say, a MetLife card and the office says that they are not a MetLife provider. The patient says, “Yes you are, you are listed as a Provider on their website.”
Essentially, no one becomes a party to a contract to which they never considered and
agreed. The same notion should apply in this situation. About 18 states have already passed laws addressing network leasing.
The image below is from an Ameritas Provider Agreement, prior to passing LB 954.
Summary of Changes
In order for the insurance company to lease their network, they must:
(1) Identify all third parties in existence in a list on its Internet website that is updated at least once every ninety days;
(2) The provider network contract specifically states that the contracting entity may enter into an agreement with a third party that would allow the third party
to obtain the contracting entity’s rights and responsibilities as if the third party were the contracting entity, and when the contracting entity is a dental carrier, the provider chooses to participate in third-party access at the time the provider network contract was entered into; and
(3) The third party accessing the provider network contract agrees to comply with all applicable terms of the provider network contract.
A dentist provider is not bound by and is not required to perform dental treatment or services under a provider network contract granted to a third party in violation of the above requirements.
Medicaid Audits
Some of you may remember in 2014, approximately 300 dentists received a Medicaid RAC Audit letter entitled Improper Payment Notification. The letter was dated April 14, 2014 and gave the dentist 30 days from the date of the letter to respond. Nebraska HHS hired HMS as its Audit contractor and focused on prophylaxis.
There were a number of flaws with the DHHS audit and the NDA was able to pass LB 315 to address those issues. Later that year, CMS changed their audit terminology from RAC (Recover Audit Contractor) to UPIC (Uniform Program Integrity Contractor). In late 2018, when CMS and DHHS launched another series of audits, this time focusing on the Pediatric dentist community and chrome crowns, we argued that LB 315 passed in 2014 prevented DHHS from using parameters in the 2018 audit.
The NDA became aware of multiple Pediatric dentist audits in 2019 and began seeking a senator to introduce legislation to address issues with the current audit. Senator Ben Hansen introduced LB 1105 in January 2020, which sailed through the Health and Human Services Committee, advancing to General File.
Then COVID hit. When the Legislature finally reconvened,
LB 1105, merged into LB 956 was included in LB 956, which the Legislature passed and was signed by the Governor on August 8, 2020.
Summary of Changes
1. Changed language to apply to ANY audit where CMS was involved (NDA passed a previous Medicaid Audit bill, but CMS changed their RAC terminology to UPIC the next year . . . DHHS argued our revised Medicaid statute didn’t apply to them.)
2. Allowed payment for services actually performed if DHHS disagreed with the service (Pedo dentists placed chrome crowns as required under AAPD guidelines and were made to pay the entire amount back)
3. Requires the same specialist to review a specialist being audited. (DHHS used a general dentist to review a Pedo’s work and ignored AAPD guidelines.)
4. Prohibits extrapolation of audit improper payment findings. (DHHS found x% of Pedo’s work was not properly documented, so they extrapolated x% of ALL of Pedo’s patients for two years and demanded entire amount repaid, even though services were provided.)