The science of denying claims

398 words

John Geyman, M.D., whose Do Not Resuscitate I am continuing to read, argues that the private medical insurance companies have made a science out of denying claims. It seems to me that he makes quite a case, though one does not necessarily have to accept his interpretation of this practice---that it is designed to maximize profits (which it no doubt is) and that government as a single-payer would not be tempted to engage in similar behavior.

When I turned 65 I enrolled in a Medicare Advantage Plan offered by Healthnet. In general I have been satisfied with this insurance. However one problem I have had with them could furnish strong ammunition for Dr. Geyman.

Healthnet includes a limited dental benefit (which pure Medicare does not), covering two cleanings and dental exams and one set of x-rays a year. The value of this coverage has proved minimal for two reasons:

First, the amount they will pay for the dental inspections and x-rays is substantially less than the actual charge, and since my dentist is not under contract with Healthnet I have to pay the entire difference.

Second, and more seriously (since I could avoid the first problem by switching to one of their approved dentists), Healthnet will not pay anything for my twice-a-year cleanings. My dentist thinks I need a more intensive cleaning which is coded as periodontal maintenance. Healthnet tells me that such cleanings are not covered.

Interestingly, when I first signed on to Healthnet several years ago, they would “re-code” this periodontal claim to a regular one and pay what they would have paid if I had gotten such a cleaning. This seemed extremely reasonable to me. But then they stopped recoding and refused to pay anything for my cleanings. When I pointed out their previous practice they claimed that the American Dental Association had decided in 2005 that “down-coding” was fraudulent and that they therefore could no longer do it.

It would obviously be fraudulent for my dentist to down-code what his office did, and his office quite properly said they couldn't do that when I asked about it. But I fail to see how it would be fraudulent for an insurance company to pay what it would have paid for a less extensive cleaning, and I suspect that Healthnet seized on the ADA decision (which probably had some other problem in mind) as an excuse to save some money.

It is too bad, since otherwise my experience with Healthnet has been good, but the dentistry issue has left a bad taste in my mouth.