When you have a problem with an insurance company not paying a claim, or if you are not happy with the services you have received from a dentist, there are steps you can take toward a resolution.
The IDA suggests first approaching the dentist and/or insurance company to resolve an issue. The next step, if needed, patients may use the IDA mediation process to resolve “quality-of-care” issues; however, we strongly suggest patients first take the following steps to resolve disputes.
Step 1: Talk to your dentist
Bring your issue to the attention of the dentist. The dentist or office manager should be able to address your issue. Simply bring it to the practitioner’s attention by calling the office.
If you do not wish to discuss the dispute or “confront” the dentist, send your complaint in writing – certified mail or by facsimile will guarantee receipt. When you contact the dentist, make sure you are prepared to discuss:
- The involved date-of-service (treatment date)
- Dollar amount in dispute
- Your issue, and
- An outcome that will make you happy
By contacting the dentist with your issue before going through other grievance processes, you will likely resolve your issue quickly.
Step 2: Contact your insurance carrier
If your issue involves an HMO, PPO, traditional health insurance company or any contracted provider arrangement (provider is chosen from a list from the insurance company), contact the customer or member service department of the insurance carrier for assistance in resolving an issue or explaining benefits and coverage. For federal or state programs, including Medicaid and Medicare, contact the appropriate government office or your assigned case worker for assistance.
If the member service representative does not help resolve your issue to your satisfaction, ask to file a “first step” formal grievance – this may be called an appeal, a reconsideration, a complaint or grievance. There is usually a multi-step approach to handling insurance complaints.
Only your insurance company can address insurance benefit coverage or billing issues. It is the patient’s responsibility to know what his/her insurance coverage and benefits are, even if the dentist’s office indicates a certain coverage will be provided. Each dentist’s office works with several insurance companies and cannot know what each patient’s coverage provides.
If the insurance-related issue still is not resolved, you can file a grievance with the Indiana Department of Insurance.
Step 3: For unresolvable “quality of care” issues, contact the IDA
The IDA has a “peer review” process to consider “quality of care” issues. However, this process will not consider issues about the appropriateness of fees, insurance issues, billing disputes, staff issues, or office policies.
If your complaint meets the IDA peer review “quality of care” criteria, you may call the IDA at 800-562-5646 for assistance through the peer review process. The process is as follows:
- The patient receives forms to complete and return to the IDA Central Office in Indianapolis
- The forms are reviewed to see if the issue meets “quality of care” criteria
- The forms will be sent to a local district dental society for consideration by a panel of dentists
To request Peer Review forms, you must complete and submit the following form:
A mediation-trained dentist will contact the involved parties and make every attempt to help you and the dentist reach a mutually satisfactory resolution. If mediation is not successful, the case proceeds to a committee hearing where a panel of dentists will review findings and recommendations for a resolution. This process is non-binding and voluntary and is allowed by Indiana state law.
Step 4: Resolving other issues
When you cannot resolve an issue involving insurance companies, you may contact the Indiana Department of Insurance and file a consumer complaint.
It is always best to have your facts ready before you file a complaint. You should have:
- The date-of-service (treatment or service date in the dentist’s office)
- Any involved follow-up dates
- Copies of receipts and agreements
- Copies of treatment plans, financial arrangements, records, etc.
In all cases, do not send originals, only copies. Briefly describe the issue or dispute. Suggest a resolution that would be fair and satisfy you. Be courteous and calm.
Ed Rosenbaum, Director of Professional Services