DPL Feature

The Queen’s Shilling

Third-party payment mechanisms are commonplace in contemporary dental practice, and it is important to understand what this really means. Dr David Hallett, CEO of ADAWA, and Dr Annalene Weston, Dentolegal Consultant at Dental Protection, explore this in the context of a recent case.

BY DR ANNALENE WESTON & DR DAVID HALLETT

Case Study

Dr X’s father proudly booked in for a checkup with his son the week after he had graduated from dental school. Dr X also scheduled his romantic partner into his new private practice for her treatment. He had been treating her since he was a student, and so saw this as a continuation of her care. Dr X has been treating both his parent and his wife ever since. Dr X was therefore shocked when he received a letter from their private health insurer stating that the fund rules and his HICAPS agreement with the fund prohibited claims made as a result of treating family members. The letter further demanded repayment of $2,800 for claims made over the last three years for service rendered for both his parents and his partner. Dr X phoned Dental Protection explaining that he had provided all the treatment claimed and had recorded this in his notes using appropriate item numbers. He had in no way acted fraudulently. Regretfully, however, most health funds prohibit these claims regardless of accuracy. Equally as unfortunate for Dr X, as an associate dentist on commission, the amount demanded by the health fund far exceeded the amount Dr X had been paid for the services. Dental Protection assisted Dr X in formulating a response to the health fund declaring the integrity of his claiming and seeking leniency in this instance as well as leave to claim for future treatments of family members. The health fund agreed to a somewhat reduced repayment sum in this instance but did not agree to future claims being made for Dr X’s family members.

Know the rules

Dr X is not the first to treat friends and family, nor is he alone in being asked to repay the money. When considering providing treatment to family members, it is crucial that practitioners read their health fund provider rules as well as the family member’s policy documents. Critically, what is the policy definition of a family member? This will give you guidance and perspective on whether you are allowed to claim benefits for treating a practice staff member or a colleague in the practice, and their respective families. If you are unsure, ask the family member to contact their fund to clarify their eligibility to claim a benefit. A supportive letter to the fund outlining the course of proposed care may assist in the ability for them to claim, however it is imperative that you do this before treatment commences, not once you have completed the care. Whilst we have known of instances whereby funds have paid some level of discretionary benefit, this is not always the case. If the fund is totally unresponsive, perhaps the family member can consider seeking out a fund that best suits them and their needs. If the fund does accept your provision of care to family members and staff, ensure that you bill and itemise in a way that is consistent with how you bill all your patients. It goes without saying the contemporaneous records ought to be kept, as they would be for every patient.

Learning Points

• Do understand the rules of the third parties from whom you make a claim • Do read your HICAPS agreement • Do consider the appropriateness of any claims made, regardless of who they are for • Do seek advice if you receive a letter from a Health Fund or Medicare regarding an issue with your claiming.