By Matthew Hironaka J.D
Have you ever been told that you should not discuss your office fees or insurance reimbursements with other dentists? Have you ever wondered why? If so, below is a refresher on federal antitrust law that prohibits certain activities and the PPO contracts provisions that prohibit you from sharing your reimbursement information with competing dentists. As well as some actions you can take if you feel that your reimbursements rates could use an increase.
The basic objective of antitrust law is to "protect the process of competition for the benefit of consumers, making sure there are strong incentives for businesses to operate efficiently, keep prices down, and keep quality up."(1.) Congress passed the first antitrust law, the Sherman Act, in 1890. This Act prohibits "every contract, combination, or conspiracy in restraint of trade." Essentially, the Sherman Act prohibits individuals/businesses including dentists and dental practices, from collectively engaging in anti-competitive activity. The Act is enforced through imposing civil and criminal sanctions upon those who engage in prohibited activities.
Some examples of what may be considered anti-competitive activity by dentists may include the following: collectively setting office fees at a certain level, collectively boycotting specific dental benefit plans, or collectively refusing to continue participating in-network with a specific dental benefit plan unless reimbursed at a demanded level of reimbursement. It is unlikely you need to be overly concerned about antitrust laws; however, you should keep in mind the type of conduct antitrust laws prohibit if you find yourself discussing your office fee information, in-network PPO participation or PPO reimbursements. Competing dentists, in particular, should be cautions if discussing any type of collective action related to setting office fees or participating/not participating with managed healthcare plans.
Simply discussing your insurance reimbursements without further action is unlikely to lead to an antitrust law violation; however, discussing your insurance reimbursements with other in-network dentists may breach the terms of a dental insurance contract. Many PPO insurance contracts contain provisions that prohibit the contracted dentist from discussing and disclosing their PPO reimbursement fee schedule information. For example, the following is a provision from a PPO insurance plan - dental provider contract:
"Confidentiality. You agree to keep confidential ... your Fee Profile ... and not to discuss your Fee Profile with any other Dentist participating in the Network."
If you review your current PPO insurance contracts and applications, you will likely find similar provisions contained within the contract's boilerplate language. Additionally, your contract likely contains consequences for breaching the contract provisions up to and including termination of the contract. Given these contractual provisions, it is prudent to use caution before discussing your insurance reimbursements.
Although discouraged in many situations, when Dentists share fees with each other it is usually for the purpose of comparing differences amongst reimbursements. This typically leads to frustration when a dentist discovers that he/she has reimbursement rates that are lower than their peers.
At Unitas Dental, we can help dental practices receive higher reimbursements through our PPO Negotiation and Optimization services. We've helped thousands of dentists across the country to achieve higher reimbursements and we'd love to speak with you about your PPO opportunities as well.
Schedule a complimentary consultation with one of our PPO Negotiation experts today.
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Matt Hironaka is the Chief Operating Officer and In-house Counsel for Unitas Dental. Matt has a business degree and worked in the banking and financial services sector prior to obtaining his law degree. Matt practiced law for 7 years with a focus on civil defense litigation. Matt defended professionals, including Dentists, in legal disputes and disciplinary board matters and further represented clients in transactional matters. Matt joined Unitas as its Operations Officer and In-house Counsel in 2014.