Insurers, Dentists Jaw at Each Other Over Mandatory Price Discounts

Andrew Kitchenman | October 9, 2014 | Health Care
Dental-care providers push bill, complain they’re being hurt financially; health plans argued that consumers have benefited

Assemblywoman Pamela R. Lampitt (D-Burlington and Camden)
Dentists in New Jersey have been feeling down in the mouth about being forced to accept discounted prices set by insurers – even for services not covered by dental-insurance policies.

But insurers say consumers have benefited from those mandatory discounts, which began in 2008 — and oppose legislation that would give dentists back the final say over prices.

Health plans have leverage, since insurers can decide against contracting with dentists who refuse to offer the discounted prices.

Providers say they’re being hurt financially because the costs of those dental services can exceed the potential payments.

The proposed legislation, S-2164/A-3411, would prohibit insurers from setting prices for services that they don’t cover.

Insurers argue that the government shouldn’t be getting in the middle of negotiations between insurers and providers, and that consumers have benefited from the lower prices.

But bill supporters argue that state regulations are in place to protect consumers from being charged unfairly high prices.

Under state law, dentists must describe the options available to patients and how much the different services will cost. Since the services not covered by insurers usually aren’t urgent, patients have time to mull over their options.

Dr. August Pellegrini of Bayonne noted a dilemma he faces as a result of the mandated price discounts: After he presents patients with the different care options available to them, he’s obligated to provide the services the patient chooses regardless of the amount he’s paid.

“There may be a loss involved on my part, but still, once (the patient is) in that treatment, I have to complete that treatment to the best of my ability,” Pellegrini said during a recent legislative committee hearing.

The state Department of Banking and Insurance doesn’t have authority in the dispute because the discounts themselves aren’t considered to be insurance coverage.

“The problem is it’s on a take-it-or-leave-it basis,” New Jersey Dental Association Executive Director Arthur Meisel said, arguing that insurers are attaching unregulated price-setting to regulated insurance contracts. “And they’re saying unless you take that as well, you can’t be a participating practitioner — I just think that is wrong.”

But Wardell Sanders, president of the New Jersey Association of Health Plans, said patients benefit from the discounts and that dentists can choose which insurers to contract with.

“We just think that if a plan and a doctor want to include this in their contract, they should be able to do that — they wouldn’t be able to do that after this bill,” Sanders said. “We fundamentally have a problem with legislative involvement in private contracts.”

One change to the proposed bill would benefit insurers and, potentially, patients. It would allow insurers to continue requiring discounts for services that the insurer normally would cover, but which have exceeded the annual dollar limit for coverage.

For example, if an insurer normally covers root canals but has an annual limit of $2,000 on how much it will pay for root canals, the insurer would still be able to require the lower price if the procedure costs more than the limit.

Sanders said this change was significant, since most dental plans have annual limits.

The Assembly Financial Institutions and Insurance Committee recently released the Assembly version of the bill, whose first primary sponsor is Assemblywoman Pamela R. Lampitt (D-Burlington and Camden). The Senate has already passed its version, sponsored by Sen. Nia H. Gill (D-Essex and Passaic) and Sen. Thomas H. Kean Jr. (R-Morris, Somerset and Union).