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At Issue: Should insurers be able to set fees for services they don't cover?
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At Issue | dental insurance mandates

At Issue: Should insurers be able to set fees for services they don't cover?

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A weekly feature on proposed changes to state and local law.

In a nutshell

Under this bill (AB109, SB131), insurers could not require dentists to set fees for certain services their customers receive if the procedures are not covered under the insurers’ policies. Third-party administrators or provider networks also could not mandate set fees for noncovered services.

Dentists may not charge such patients more than the usual nondiscounted fee for a noncovered service, however.

The bill bans insurers from providing nominal coverage for a dental or related service, making the procedure a covered service, to avoid the requirement under the bill that prohibits setting fees for noncovered services.

The case for it

Dr. Paul Levine, vice president of the Wisconsin Dental Association, said four years ago a large national insurance company began requiring dentists contracted by the company to charge its customers fixed amounts for services the company did not cover.

Those services typically included teeth whitening, veneers, high-end cosmetic treatments and some implants.

Other companies have since done the same, Levine said, forcing a lot of dentists to raise their fees for people not covered by those plans to make up the costs. The alternative, he said, is for dentists to risk losing patients by not dealing with insurance companies that have a “take it or leave it” approach to the terms of their contracts.

Thirty other states have passed laws prohibiting insurance companies from setting fees to be paid by people they insure for services the companies don’t cover, Levine said.

“What it comes down to is, it levels the playing field and makes things fair,” he said.

The case against it

Cheryl DeMars, president and CEO of The Alliance, a Madison-based cooperative of employers working to control health care costs, said the measure “undermines our ability to work on behalf of both employers and their employees.”

“We use data to determine what a fair market value price is for services,” DeMars said, adding, “We believe these prices should apply whether it’s the employers or the employees who are paying for the services. … We wonder why a dentist or other provider would accept one price from an employer but would expect another if it’s coming from a consumer.”

DeMars said service providers can negotiate prices with insurance companies and networks. “No one has to agree to the terms,” she said. “We believe disputes or concerns should be worked out during the negotiation talks or in the court of law, if it comes to that, but it’s not something that should be legislated.”

To get involved

To contact your lawmaker about this or any other bill, call the legislative hotline, which is staffed from 8:15 a.m. to 4:45 p.m. weekdays at 608-266-9960 or 800-362-9472. To send an email, go to the Legislature’s website at legis.wisconsin.gov, select “Assembly” and follow the link.

— Sandy Cullen

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