Ethics Case Study #2: Representation of Patient Fees
Instructions:
Begin this 2 MCE Credits course by reading the case study presented below. Through having previously taken the Foundation's course on Ethics and Jurisprudence, you will be equipped to apply the ethical principles discussed in that course to the case study presented. After reading the case, you will be presented with three case-specific questions to consider. Each of these questions will be related to the content discussed; upon answering each of the questions, you will receive detailed responses regarding the correct answer. Please note that upon completing the 10 question quiz with a passing score of at least 65%, your score will be automatically recorded and you will be issued a continuing education certificate for 2 MCE credits within three-days of completion. Should you have any questions, please contact the NYS Dental Foundation at (800) 255-2100, ext. 282. Thank you for choosing the New York State Dental Foundation for your continuing education.
STEP ONE: Read through the case study below. When you complete the course, please continue to Step 2.
Dr. Mitchell’s usual fee for a crown is $800.00. Dr. Mitchell has signed participating provider agreements with several participating provider organizations (PPOs), including the Empire Dental Plan.
A patient presented in Dr. Mitchell’s office with coverage through two carriers. The patient is covered by his employer through Empire Dental. He has secondary coverage through his spouse with New York Dental.
Dr. Mitchell considers the Empire Dental plan “primary”. Therefore, she first submitted a claim to Empire Dental. The claim identified Dr. Mitchell’s charges (i.e., the patient’s fee) as $800.00. The allowable fee in the Empire Dental Plan for the procedure is $500.00. Empire sent a check for $500.00 to Dr. Mitchell as reimbursement for the patient’s claim.
Dr. Mitchell’s contract with Empire Dental states that, when a patient has coverage with a second carrier, the dentist may seek his/her usual charges from the second carrier.
Dr. Mitchell then submitted a claim to New York Dental for this patient. The claim identified Dr. Mitchell’s charges (i.e., the patient’s fee) as $800.00, reflecting a payment by the primary carrier of $500.00. The New York Dental plan’s UCR fee for a crown is $700.00. New York Dental reimburses 80% of its UCR or $560.00. New York Dental sent Dr. Mitchell a check for $60.00 representing the difference between its allowable reimbursement and the $500.00 already paid by Empire Dental.
A month after receiving the check from New York Dental, Dr. Mitchell received a letter from New York Dental requesting a refund of its $60.00 payment.
STEP 2: Click here to complete the short quiz corresponding to the above case study. You will need to complete this quiz in order for your continuing education certificate to be issued.
You may now continue to the next case study.
Click here to continue to Ethics Case Study #3 >>>
E-mail the instructor with any questions you may have regarding this course.
The New York State Dental Foundation is an ADA-CERP approved provider of continuing education.
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