by Richard D. Weber, J.D.
MDA Legal Counsel
Published in the May 2002 issue of the Journal.
Question: Two years ago, one of my patients was hit in the mouth at work with an automatic nailer. I did not crown the teeth, as I believed further treatment (endodontic) was going to be necessary. I did composites. The patient recently fractured a composite when he bit into something. Workers' compensation is refusing to pay on the composite repair claim. Is there a mechanism to appeal the workers' compensation decision? Can I bill the patient for the repair? Can I obtain my customary fee? Who can I contact when I have a workers' compensation question?
Answer: Michigan's Workers' Disability Compensation Act covers dental and other health care services required to correct the effects of a work-related injury. A dentist billing a carrier (e.g., an insurer, self-insured employer, or a fund referenced in the act) for a covered service must accept the maximum allowable payment ("MAP") amount as payment in full, and is not permitted to balance-bill the patient. In other words, a dentist may not bill the patient for the amount that is disputed by a carrier, or for the amount that exceeds the MAP (i.e., the difference between the MAP and a dentist's customary fee).
The MAP is the maximum amount payable to a dentist for rendering services covered under the act. When a dentist's charge is less than the MAP, or if a dentist has a contract with a carrier to accept discounted fees, payment is made at the lower amount. Most MAP amounts are pre-determined fixed fees, although some dental procedures do not have pre-calculated fees.
If it is ultimately determined that a patient did not suffer a work-related injury, a dentist may bill the patient or the patient's insurer for the dentist's customary fee, absent a different fee arrangement with the patient or insurer.
When a dentist is dissatisfied with a carrier's reduction or denial of a claim, the dentist may submit to the carrier a written request for reconsideration within 60 days after receiving notice of an adjusted or rejected claim. The request must include a detailed explanation of the disagreement, and documentation to substantiate the charge/service in question. A dentist may not dispute a payment simply because of dissatisfaction with a MAP amount. The carrier must re-evaluate the original claim and accompanying documentation and respond within 30 days. The carrier must explain the reasons for its decision and cite the specific policy or rule supporting the adjustment or rejection.
If the dispute remains unresolved, the dentist may file a request with the Michigan Bureau of Workers' Disability Compensation for a mediation hearing before a magistrate. The dentist should normally do so within 30 days of receipt of the carrier's denial of reconsideration. A dentist may also request a mediation hearing if a carrier fails to respond to a claim or if the patient's case is contested. A dentist who is dissatisfied with a MAP amount or payments under a contract is not eligible to request a mediation hearing.
A dentist can request a mediation hearing by filing Form 104B with the bureau. Forms can be requested by calling (888) 396-5041, ext. 3, or by mailing a request to: Claims Division, BWDC, P.O. Box 30016, Lansing, MI 48909. E-mail requests to email@example.com, or fax to (517) 322-1808. All requests should include a contact name, phone number, mailing address, the name of the requested form, and quantity.
Dentists with questions on the bureau's health care services rules, including the procedures for resolving disputes with carriers, can call the bureau at (517) 322-5433. Because the bureau does not pay or review claims, questions concerning the status of a claim must be directed to the carrier. Dentists who cannot get carrier information from the employer can contact the bureau at (517) 322-1885. Dentists should have available the employer's name and address and date of injury or date of first symptom for the reported illness.