DeLayne Lefevre has two dental practices serving thousands of patients in Madison and Delaware counties. Her patient, whom she called Jim, needed dentures and extractions but his specific Assignment of Benefits (AOB) with his insurance company didn’t allow direct payment to Lefevre.
“I agreed to allow Jim to pay once his insurance carrier sent him the check. A couple of months passed without any payment so my team called the insurance company and asked where the payment was. They said they’d already processed that claim and they sent the check to Jim,” Lefevre detailed before the Senate health committee on Wednesday.
But when Lefevre called Jim, he’d already spent the money thinking it was an insurance refund check.
“Jim says … ‘I don’t have any money to pay you, Dr. Lefevre, but I sure do like my teeth,’” Lefevre recalled. “So he got the teeth, he got the extractions and I never got paid for it.”
In another type of clinic, a patient’s insurance might pay the bill directly. But dentists and insurers have a different relationship. Because of that, dentists say that many patients simply walk out of their offices without paying or get a check from their insurance and spend it without knowing it’s meant for their dental care.
Senate Bill 132 seeks to remedy that by adding some additional regulations on insurers and, crucially for Lefevre and others, allow patients to assign benefits to dental providers whether or not their dentist is in-network.
The omnibus measure — authored by Fort Wayne Republican Sen. Liz Brown — also includes requirements for the Family and Social Services Administration’s rollout of Managed Care for Long-Term Supports and Services, tweaks telehealth law, eases licensing for foreign-born nurses, eliminates certain requirements for health facility administrators and more.
Dental provisions draw debate
Lefevre, speaking as part of a team from the Indiana Dental Association supportive of the bill, said she now collects upfront for new patients or those whose out-of-network insurance policies mimic Jim’s with an AOB that doesn’t transfer rights and benefits to a third party like Lefevre.
“People hate to go to the dentist; they’re scared, they’re anxious for whatever reason … now imagine what they have to go through to now change their provider because their insurance carrier won’t pay us as dentists,” Lefevre said. “The added stress to that — they may choose not to go to the dentist — … that is a loss of continuity of care.”
But not everyone agreed, including one of the state’s largest non-profit dental insurance providers: Delta Dental of Indiana, which has a participation agreement with roughly 80% of the state’s dentists.
Dentist Jeff Johnston — Delta’s senior vice president and chief science officer for Michigan, Ohio and Indiana — noted key differences between in-network and out-of-network dentists, including requiring free replacements for improperly fitted crowns.
“Insurers require dentists to meet certain credentialing standards, abide by claims processing policies and adhere to quality of care standards … (that) offer significant cost and treatment safeguards for patients,” Johnston said. “We are convinced that (AOBs) will yield smaller networks (and) it will be creating an incentive for dentists to drop out of an insurance network because they’re getting the payment directly.”
“Dentists can and will charge higher fees to avoid the insurance costs and quality protections. In other words, patients will end up paying more and receiving less,” he continued.
Johnston said Indiana allowed AOBs in 2008 and subsequent efforts to tweak the dental insurance process resulted in one change: a requirement for insurers to specify if a payment is meant for dentists and not the patient.
“That’s as far as the General Assembly has gone in the past, I think, because of concerns about the protections that will be lost for patients,” Johnston said.
Delta’s testimony was repeated by the Insurance Institute of Indiana, which said insurers would also be negatively impacted as providers dropped out — a cost they claimed would be passed onto consumers — as well as the Indiana Chamber of Commerce, which called AOBs a “billing and collection issue between a doctor and patient.”
Brown pushed back, saying she’d incorporated previous Delta concerns into the bill and called for insurers to pay dentists directly — even if it meant a reduced sum for out-of-network providers.
“If the Delta Dental product and being in-network is as seamless and as easy and competitive, then there shouldn’t be any change. But we’re giving the patients more authority and more choice,” Brown said. “I’ve asked for that information … (to) prove to me, in other states, that network (participation) will go down.
“… I’ve never received that information.”
Language for long-term care, nurses
Another portion of the bill includes payment deadline requirements for the Family and Social Services Administration when it goes live with a new managed care plan for long-term care, otherwise known as PathWays for Aging.
Hoosiers in nursing homes and assisted living facilities or those utilizing home- and community-based services are the last population not under a managed care plan, which is set to roll out this summer. Brown said this bill doesn’t jeopardize or slow down that rollout but that other states transitioning to such plans had reported delayed payments to providers.
Managed care is a model for delivering health care services in which one key entity manages each aspect of care for a consumer for a flat, up-front sum per person, rather than providers individually charging the state piecemeal for each service, also known as fee-for-service.
Brown, in her introduction, recalled a failed managed care rollout from the FSSA regarding transportation. She emphasized that while FSSA hadn’t yet done anything wrong, it was a precaution against late payments.
“We’re talking about nursing homes and assisted living people — our most vulnerable population,” Brown said. “This is not meant to be punitive.”
FSSA didn’t testify on the bill, though Brown conceded agency officials have concerns.
The Indiana Health Care Association (IHCA) and LeadingAge Indiana, which represents nursing home and assisted living operators, have expressed hesitation previously about managed care and supported the bill’s new protections.
Nick Goodwin, the director of government affairs for IHCA, said his organization wanted to ensure a “continuity of care.”
“Thirteen states have implemented a mandatory comprehensive statewide managed care program similar to what Indiana is trying to do and another 15 have a blend,” Goodwin said. “We looked at those states and many of my members are multi-state operators (who) have gone through this transition and they said the disruptions to payment were the most concerning aspect.”