Ask the Lawyer

Q: I have always worked on my children's teeth. Now they are grown and established with careers of their own with full benefits. I submitted a bill to my son’s dental insurance and was paid. A month later I received a request from a firm asking for a refund for the exam, prophy, and full mouth x-rays. The reason stated on the request for refund was that the insurance does not pay for work done by a family member. I could not understand why not so I called the number in the letter. The first person I explained the situation to told me this was not an uncommon situation. His recommendation was to bill under another doctor in the office and that was how other offices got around this. I felt the problem was the policy and I was not looking for a way to "get around the problem."

Why was this policy permitted and accepted in the first place? The answer I got was that there were some health professionals that cheated in the past by billing for services that were not performed on their family members. To me this exclusionary policy implied guilt across all health care providers and seems wrong.

He referred me to another specialist in their office. She basically said the same thing but could offer no better justification for the policy. She later checked with a specialist in her office and told me that in my specific case, even if the other dentist in my office did the work I would not be paid because the dentist is an employee of mine and did not bill under another tax ID number. I was so frustrated by these policies so I asked specifically for copies of the written policies and the justification for them. She said she would send them but it has been weeks with no reply. The letter also stated that if the amount is not refunded by the now past deadline, they would take it out of future payments.

A: Dear Stressed in Seattle,

I am surprised by your question. I have not come across a third party payer that refuses benefits to a provider based upon family relationship. I agree that this policy seems silly and misguided. However, these type of payment issues are almost completely governed by contracts. Your son, I assume through an employer, has an insurance policy which provides dental benefits. That is one contract. A second contract is between your practice and the insurance carrier. Your practice may or may not have a contractual relationship with this insurance carrier. If either of these contracts prohibits an insured from receiving professional services from a relative then you may be out of luck.

You have done the right thing by asking for a copy of the policy/contract which prohibits you from treating your son. I would be surprised if they could produce this policy. Next, I would ask your son to take this issue up with his employer. Obviously the employer, who pays for this benefit, should be able to get the attention of the insurer. If your son works for a larger employer, he should speak to the Human Resources department about this situation. If it is a smaller entity he may be able to speak to the agent that sold the coverage to his employer.

A final word of advice, I would not devote much more effort to the situation right now. You have been paid and still have the money. Should they attempt to offset future work to recover money from your son’s services, then I would take action. Your son can exert some leverage via his employer. If you do not have policy language by the time they pull back funds I would turn the carrier into your state department of insurance. I have also had some success in filing small claims against third party payers under the theory you are a beneficiary of the insurance contract. This may be more trouble than it is worth to you, but it usually has the desired effect. I wish you all the best with this and please let us know how the story ends.           

Q: How do you best handle divorced parents with varying and sometimes changing custody agreements?

A: Dear Dealing with Divorces,

Unfortunately, payment issues for minor children of divorced parents come up frequently. Often times a divorce decree will specify which parent is responsible for medical/dental expenses for a child. You need to know that this divorce decree is effective between the former spouses and does not impact your practice. You are not listed on the court order, just the two former spouses. In most states, the law is that both parents are equally responsible for their child’s medical care. This raises the situation that one parent may pay for the care, but the other is responsible for reimbursing him or her. I suggest you contact a local attorney to determine if your state has a statue imposing financial liability on both parents for their child’s medical care.

In most states, there is a distinction between legal custody and physical custody of a child. Physical custody is most often referred to as visitation. Legal custody issues are referred to as either joint custody or sole custody. Issues related to physical custody are less important to you as a dental provider. The legal custody has significance for who you can discuss a child’s dental health issues with. If there is joint custody over the child, you may speak to both parents about confidential dental issues regarding the child. However if one parent has sole custody you will not be able to speak to the non-custodial parent about your patient’s dental issues. Again this distinction is provided as a general overview. State laws vary and you may wish to run this past your local attorney.