22 minute read
PRACTICE
ALL THAT GLITTERS IS NOT GOLD
Is it true all that glitters is not gold?
In 1907, a Chicago dentist named W. H. Taggart introduced a casting method for small gold inlays. Then, in 1936, a Danish engineer, Thoger Gronborg Jungersen, filed a patent for a method of manufacturing precision gold objects utilizing the lost wax technique combined with a centrifugal casting machine. This ushered in the modern era of indirect cast gold restorations, including inlays, onlays, ¾, ⅞, and full-coverage crowns. Over the years, many refinements to this process have been introduced that have enhanced control over the size of the casting and have greatly improved the precision nature of the process.
Consider how many of these restorations have been utilized since they were first introduced. The number is likely in the tens, or even hundreds of millions. Wow! The ability to reinforce tooth structure in a very conservative way with these restorations was a significant breakthrough. To say that many teeth have been saved by indirect cast gold restorations is, indeed, an understatement.
As a witness to the remarkable nature of these restorations, it is likely that many dentists reading this article are sporting at least one, if not more, indirect cast gold restorations in their own mouths.
As you well know though, partial coverage is really where gold shines. There is not a less-invasive, longer-lasting restoration in our toolbox. It is not uncommon for many of these restorations to be in service for more than 60 years.
With that as a backdrop, according to a 2018 survey of 844 dentists across the United States, less than 3% of all crowns placed were cast metal, let alone cast gold. Currently, worldwide the number of cast gold restorations placed is likely less than 1%.
The University of Utah School of Dentistry is one of only a handful of dental schools in the country that still teaches indirect gold restorations, including partial coverage. While visiting recently with a colleague, he indicated that his 2008 graduating class was the last class at his dental school that was taught indirect gold. Is the indirect gold restoration becoming a lost art? There are several obvious reasons why gold is falling out of favor; but, poor performance is not one of them. Do we give our patients ample opportunity to choose gold? Are we taking the time necessary to educate them regarding the benefits of gold? Are we, as dentists, maintaining our skills with regards to gold, or are we simply taking the path of least resistance and doing what is most expedient? Whatever the reasons for the decline, we still have a responsibility to pursue the best for our patients.
I am not advocating that we abandon the myriad of ceramics at our disposal. They are amazing products also. I love using them. They have expanded our ability to provide highly esthetic and durable restorative options for our patients. However, there are still situations wherein indirect gold, especially partial coverage, is the most appropriate restorative option for a patient.
That being the case, then I would contend we have a responsibility to make that option available for them. Give our patients the same opportunity to choose gold, like you would for yourself. All that glitters may not be gold, but no one can argue with the fact that for some restorative situations, nothing outshines gold.
Mark R. Taylor, D.D.S., UDA Secretary
DISABILITY INSURANCE: DO I REALLY NEED IT?
A Disability Insurance Attorney’s Perspective
More than 1 in 4 of today’s 20-year-olds will become disabled before reaching retirement age, according to the Social Security Administration.1 A recent study ranked dentistry as one of the most hazardous careers, outranking firefighters, nuclear equipment operation technicians, and oil and gas derrick operators.2 And dentists are also near the top of the list for risk of COVID-19 infections, the long-term consequences of which remain largely unknown. 3
In our practice, which focuses on professionals’ “own occupation” disability claims, the majority of our clients are dentists. Many are in their late 30’s or 40’s and never expected to be facing a disabling condition at the height of their careers.
Bottom line—if you are a dentist, you should have a plan for protecting yourself financially if you can no longer practice.
What are the Most Common Reasons Dentists File for Disability?
Many dentists view disability insurance as something they only will need if there is a catastrophic event and they are severely injured. However, the most common dentist disabilities we see are slowly progressive musculoskeletal disorders, mental health conditions (such as panic and anxiety disorders), and progressive vision loss. These conditions may seem less dramatic than the loss of a limb or a serious accident but are just as devastating for dentists who rely heavily on their sight and need to be able to sit for extended periods of time, keep their hands steady, and operate with precision within very small confines and margins.
Notably, the Council for Disability awareness has also found that musculoskeletal disorders, such as arthritis, back pain, and spine/joint disorders, are among the leading causes of disability.4 For dentists, the risk of these disorders ending their careers is heightened, as a dentist can spend up to 60,000 hours in a lifetime working in tense and distorted positions.5 Many of these conditions are chronic and exacerbated by the practice of dentistry. Over time they can progress to a point where continuing to practice not only jeopardizes patient safety, but also the health of the dentists themselves.
What Do I Need to Be Aware of if I Think I May Need to File A Disability Claim?
Hopefully, you will be able to practice safely, without interruption, and retire on your own terms. But if you do end up facing a disabling condition, it is important that you go into the claim informed and prepared.
1 See Social Security Administration, Facts, https://www.ssa.gov/disabilityfacts/facts.html, last viewed Dec. 7, 2020. 2 Andy Kiersz, The 32 most dangerous jobs for your health, Business Insider, Mar. 8, 2019. 3 See Franziska Beier, DTI, SARS-COV-2: Dentistry tops list of most dangerous jobs, Dental Tribune, June 23, 2020. Understand Your Policy Most dentists know that they should purchase “own occupation” policies. However, many dentists are not aware that there are several variations of “own occupation” policies that are not true “own occupation” policies.
A true “own occupation” policy allows you to earn income in a new occupation and collect your full total disability benefit.
When dentists come to us needing to file a claim, virtually all of them believe that they have a true “own occupation” policy because they asked for an “own occupation” policy and, when they received it, they checked for the phrase “own occupation” in the policy schedule or summary. However, many policies use the phrase “own occupation,” but add additional qualifications or limitations that you may not be expecting.
Here are just a few examples of some common variations that use “own occupation” language but are not true “own occupation” policies:
• Own-Occupation with “Offset/Work” Provisions:
These provisions reduce your benefit amount if you work post-disability, even if it is in a different occupation. Sometimes these provisions go so far as to require you to work in another capacity, if you are able, and give the insurer the ability to offset benefits as if you were working full-time if they think you can go back to work. • Own-Occupation with “No Work” Provisions: These provisions cut off your benefits if you go back to work post-disability—even in a job that is completely different than your prior occupation. • Shifting “Own Occupation” Provision: These provisions allow you to receive benefits based on your inability to work in your prior occupation, but only for a limited period of time (usually somewhere between 2 to 5 years). After this window has passed, you can only continue to receive total disability benefits if you are unable to work in any occupation. If your policy has one of these “own occupation” variants, it does not necessarily mean that you cannot collect or that you should give up on your claim. However, it does mean that you need to read your policy carefully and understand how it works before you file, so that you are prepared to make a claim that is consistent with what is permitted under your policy.
4 Council for Disability Awareness, What Are the Most Common Causes of Disability?, https:// disabilitycanhappen.org/common-causes/, last viewed Dec. 7, 2020. 5 A. Grupta, et al., Ergonomics in Dentistry, Int J Clin Pediatr Dent 2014; 7(1):30-34).
Additionally, if you have a policy that allows you to transition to new employment, insurers will closely scrutinize whether the new job has any overlap with your prior occupation’s duties. Accordingly, if you are a specialist, it can also be helpful if your policy contains a specialty-specific definition that defines your occupation narrowly as the specialty you were practicing prior to the onset of your disability.
Understand the Process Many dentists assume that all they need to do to collect disability benefits is notify the company that they cannot work and provide a signed statement from their doctor confirming that they are disabled. However, the process is much more involved than that.
Unlike other insurance claims, most disability policies require you to continuously establish your ongoing eligibility for benefits each month. Each month, the company takes into account any new developments and makes a new determination as to whether you remain disabled under your policy. Even if your disability claim is initially approved, further evaluations and investigations can (and do) occur throughout the lifetime of the claim. Be Prepared for the Claim Investigation, Which Often Begins at First Contact Many disability insurers are now interviewing dentists in the very first call that the dentist makes to request a claim packet. The length of these calls and the questions asked vary depending on the insurer. However, at a minimum, you should not call in to request a claim packet until you understand how your policy works and the nature of the claim you are making.
Disability policies are complex and often provide for multiple types of benefits designed to apply to different situations. Before filing a claim, dentists should read through their policies and consider the following:
• Does my policy allow for total or partial disability benefits, or both? Am I filing a total disability or partial disability claim? • Do I have a true own occupation policy? Can I work and collect benefits? Will working in a new job offset or otherwise impact my benefits under my policy? • Am I keeping or selling my practice? Am I hiring an associate? How will this impact my claim?
Continued on next page.
MCNA Insurance Company is pleased to administer benefits for the Utah Medicaid Dental Program.
MCNA is a provider-centered organization committed to helping dentists serve Medicaid and CHIP enrollees. We provide dentists with leading-edge technology and superb customer service support to reduce missed appointments and encourage patients to seek timely dental care.
For more information, visit us online at: www.mcnaUT.net
Disability Insurance: Continued from previous page.
• Do I have a sufficient treatment history to prove up my disability? What is the long-term treatment plan? Does it fit with the care requirements for my policy? Is surgery an option? How will I respond if the insurer pressures me to undergo surgery? • How is occupation defined under my policy? Do I have a specialty-specific policy? Have I been practicing in my specialty? Have I modified my occupation by changing my duties, reducing my hours, or beginning a new job? This last point trips up a lot of dentists because many disability policies now define your occupation as the “occupation or occupations” that you were engaged in prior to the date of disability. When facing slowly progressive conditions, many dentists cut back their hours and look for other, non-clinical ways to generate income. Depending on the policy, this can limit a dentist’s ability to qualify for certain disability benefits later on. Consequently, if you have a slowly progressive condition, you should not make these types of changes without evaluating how they could affect a future disability claim.
What Should I Expect Once the Claim Has Been Filed?
If a dentist is facing a permanent disability and has several years left on his or her policy, the company can end up paying out millions of dollars over the lifetime of the claim. Because of the significant amount of money at stake, insurance companies often devote significant time and resources into investigating dentist claims.
While each claim is different, over the course of a claim investigation, insurance companies will typically:
• Seek to speak with others about your condition.
This may include treating providers, pharmacies, insurance agents, financial institutions, the Social
Security Administration, family, friends, co-workers and employees, among others.
• Seek to gather a wide range of documentation for their file, beyond what they request from you
directly. This may include medical records, tests, or consultations, prescription history, mental health records, records for substance abuse treatment, court records, occupational data, employment history, driving history, financial statements, and/or your earning history. • Schedule face-to-face interviews with you. Many insurers seek to interview you in your home, so that they can view your surroundings to see if they can find discrepancies in the claim, or learn more about you so that it is easier for them to conduct surveillance. • Order an In-Person Exam. The insurance company may claim that an in-person exam is needed to verify a disability. In some instances, this may be the case.
However, some insurers use these exams to criticize your provider’s course of treatment, dispute your own provider’s conclusions and diagnoses, or challenge your reported limitations (particularly symptoms that are subjective in nature, such as pain and numbness). Most disability policies also provide that refusal to participate in an exam allows the insurance company to deny a claim or terminate benefits.
• Use a private investigator to conduct surveillance.
The insurance company may employ a private investigator to conduct photo, video and/or online surveillance, in an attempt to find discrepancies in your claim or evidence of “malingering.” This can pose a particular challenge for dentist claims, as oftentimes a dentist’s symptoms and limitations may be nuanced and/or significantly alleviated once he or she steps away from the demands of practicing. This process can feel very invasive and, if you have never experienced it before, it can be hard to tell whether your insurer is taking things too far. If you feel your insurance company is being too aggressive, an experienced disability insurance attorney can help you to assess the scope of the investigation and advise whether the insurer has engaged in any improper conduct.
Do I Need an Attorney/How Do I Know If I Have Complex Claim?
While there are certainly claims that may not require attorney involvement—for example, a disability claim due to the loss of a limb or something very serious, such as paralysis from the waist down—in our experience dentist claims are typically not that straightforward. As noted above, many of our clients have more nuanced conditions, such as slowly progressive radiculopathy due to degenerative disc disease. Others have conditions like a tremor, that may not prevent them from working in other jobs, but have a significant impact on their ability to work as a dentist. Others have mental health conditions (anxiety disorder, panic attacks, PTSD) that cannot be verified by a single, definitive objective test.
Obviously, if your claim is denied or you have a dispute over policy interpretation, you may need an attorney to become involved to resolve the matter. That being said, lawsuits with insurance companies are often costly, stressful, and, in some instances, can drag out over several years. Even if you prevail it can be an exhausting process.
Consequently, in our view, it is more prudent to approach your claim carefully from the outset and address any concerns that the insurer may have over the course of the investigation itself, so that you are not placed in a position where benefits have been cut off and your only option is a lawsuit. In our experience, the most common areas where complexities can arise in dentist claims include:
• The timing of the claim (particularly in situations where a disabling condition is slowly progressive); • Claims made by dentists who own their practice and need to decide whether to sell, bring on new associates,
or keep working in a limited capacity; • Claims where the underlying condition is a diagnosis by exclusion; • Claims involving multiple co-morbid conditions; • Claims involving recommendations for or against surgery; and • Claims involving mental health conditions.
This is not an exhaustive list, but if your claim encompasses one or more of these areas, it is a good idea to at least consult with a disability attorney to determine what issues may arise over the course of your claim.
The Takeaway
If you are a dentist, you should have disability coverage that protects you if you can no longer practice. If you need to file a disability claim, you should take it seriously and not go into the claim blindly. If you are not able to locate a copy of your policy, request a duplicate and keep it in a safe place so that you have it if you need it. Before selling your practice or making changes to your occupation, you should carefully consider how those decisions could impact your ability to collect under your particular policy. And if you believe that there may be any issues with your claim, you should speak with an experienced disability attorney as early as possible so that you can ensure that those issues are properly addressed and resolved.
* Derek R. Funk, Esq. is an attorney licensed in Utah and Arizona. His practice is solely dedicated to handling professionals’ “own occupation” claims and he works with dentists at all stages of the disability claims process.
The information in this article has been prepared for informational purposes only and does not constitute legal advice. Anyone reading this article should not act on any information contained herein without seeking professional counsel from an attorney. The author and publisher shall not be responsible for any damages resulting from any error, inaccuracy or omission contained in this publication.
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801.298.4242 | ctc-associates.com Randon Jensen | Larry Chatterley
THE UDA OFFICE IF FIELDING MULTIPLE QUESTIONS REGARDING TEMPS. THIS IS A GREAT REMINDER.
Temporary employees (Temp) are defined as individuals hired to assist an office to meet increased short term needs. There are many reasons why a dental office needs a Temp. For example, Mary calls in sick at the last minute, Joni’s having a baby and the office needs a Temp for a month, and unexpected patient “over-load” for cleanings. And the list goes on. However, it’s important to understand the legal and payroll implications of hiring Temporary employees. That is, when a Temp comes into your office, what are you truly responsible for? Below is a list I’ve put together to assist you navigate this minefield. These do’s and don’ts will hopefully help you steer clear of potential issues with Utah employment laws, Federal tax laws as well as several other laws that apply. Please be advised that this is not legal or tax advice and that you should consult an attorney or tax expert to understand how these laws specifically apply to your office.
Payroll considerations:
According to Utah Employment Law you must pay the Temp for hours worked in your office including any training, working interviews or other administrative assignments. Also, each Temp will need to complete a W-4 and you must withhold taxes according to their W-4 selections.
Independent contractors/ 1099’s:
When you give someone a 1099, it means that the government considers them to be self-employed. Independent contractors are responsible to pay their own taxes, including Medicare and Social Security payments, to the IRS. In some cases, independent contractors are required to estimate their annual income and make quarterly income tax payments to the IRS. As you know, office staff need to be directly supervised by a licensed Dentist and therefore cannot be considered independent contractors. This means all office staff need to be employed by the Dentist. Issuing a 1099 to an employee under your supervision is a common mistake which may result in an audit from the IRS and/ or the state. According to the IRS website https://www.irs.gov, mis-classifying employees as independent contractors is one of the main reasons for an employee audit and failing to provide W-2 forms can subject an employer to back taxes of as much as 41.5% of the contractors’ wages. These penalties may be applied retrospectively for three years. Regardless of whether the Temp has made more or less than $600 in your office, they still cannot be self-employed and shouldn’t receive a 1099
Unemployment or Workforce Services:
Once you’ve paid the Temp, you need to register them as a new hire on Workforce Services website (https://jobs.utah.gov/) according to the Employment Security Act.The unemployment insurance program is operated on general insurance principles wherein the employer pays the contributions into the Utah Unemployment Compensation Fund (trust fund) to sustain the program. If the Temp ever files for unemployment you will be sent a letter about your potential costs based on your contribution rate. If you’re unsure about your coverage call Utah Workforce Services 801-526-4400 for additional detail.
Worker’s Compensation:
It is also important to know that the Temp employee also falls under your worker’s compensation plan. That is, if they poke, pull, fall, trip, knock or flip there’s administrative work to do in addition to sending them to instant-care or emergency room! Remember to call your carrier to ensure you have Temp coverage or fill out a form online with your company of choice. I found the Workers Compensation Fund easy to work with. Their phone number is (385) 351-8000.
Best-Practices:
While this shouldn’t be news to anyone, it needs constant repeating. There always needs to be a current licensed Dentist physically overseeing the office!! That goes for all the dental staff and patients. Another safeguard is to develop a list of what your expectations are for the Temp. Create a list of your office policies and what the Temp needs to do while Temping in your office (sterilize the room, where the barriers go, how to sterilize instruments, who take X-rays, etc.) have the Temp sign and date it so you know they understand what to do so there’s no questions or problems later.
Outsourcing the Problem:
Outsourcing these issues to a Professional Employer Organization (PEO) may be the way to go! POE’s like Doctors Staffing & Resources, Inc. will take care of the payroll, payroll taxes, Workforce Services and Workers Compensation for your Temporary employees. Some think of this as Doctors Staffing and the Dentist co-employing the Temp! That is, the Dentist oversees procedures, protocol, etc. and Doctors Staffing and Resources will handle the payroll, Workforce Services and Workers Compensation. Doctors Staffing will then ensure that the employee will be paid in compliance with all applicable state, federal and IRS regulations. Dr. James D Johnson of South Jordan said, ‘Doctors Staffing has saved me countless hours of record keeping and hassle in regards to Workforce Services and year end accounting records for Temporary employees”. As we all know, the “Gig Economy” is growing, and the IRS and state want to make sure that every person is correctly categorized and all taxes are correctly paid. Make sure you go over all this with your accountant and you’re ready for any audit that comes your way! This article was written by Stephanie Sawatzke, President of Doctors Staffing & Resources. She has over 25 years’ experience serving the needs of the Utah Dental Community. She can be reached at (801) 301-3440. Reprinted from Jan/Feb 2020 issue of the UDA Action.
Just prior to leaving office, President Donald J. Trump signed “The Competitive Health Insurance Reform Act of 2020” into law. The legislation, which repeals the antitrust exemption for health insurers, including dental insurers, passed the United States House of Representatives in September 2020 and the U.S. Senate in December 2020.
For nearly 75 years, health insurers have enjoyed an exemption from federal antitrust laws under the McCarran-Ferguson Act of 1945. The new law now makes the conduct of health insurers subject to much of the nation’s antitrust laws like all other U.S. businesses. The purpose of the new law is to improve transparency and competition in the health, dental and vision insurance marketplaces.
This is the culmination of several years of advocacy efforts by the American Dental Association and other organizations. Over the last several years, the ADA has provided congressional testimony on multiple occasions arguing in favor of repealing the health insurance industry’s antitrust exemption. According to the ADA, repealing the health insurers’ antitrust exemption would enhance competition and “compel insurance companies to deal more fairly, effectively, and creatively with both consumers of dental services and with providers.” ODA Executive Director David Owsiany, a lawyer who served on the staff of the U.S. Senate Judiciary Committee at the beginning of his professional career, stated that the actual effect of the new law will play out over time. “Because health insurers have had this exemption from antitrust laws for so long, it is unclear to what extent health or dental insurers have engaged in collusive anticompetitive behavior,” said Owsiany. “This new law will now empower the Federal Trade Commission and the Department of Justice to engage in investigations and enforcement activities if they find evidence of such collusive activity.”
The U.S. Department of Justice issued a statement hailing passage of the new law stating that it will strengthen the Department’s ability to “investigate and prosecute anticompetitive behavior.” According to the Department of Justice spokesperson, “Americans deserve competition in health insurance markets just as they do in any other industry.”
ODA Today February 2021
