The Nebraska Dental Association has sued the state's Department of Insurance and is asking a judge to block its interpretation of when insurance companies can dictate the fees dental providers charge for services.

The group says a notice issued by the Department of Insurance on Dec. 8, 2014, and a bulletin July 22 by Bruce Ramge, its director, interpreting two state laws, have led to billing issues for dentists across the state.

"Our offices were getting in shouting matches with claims companies over this statute," David O'Doherty, the association's executive director, said Wednesday.

The lawsuit filed in Lancaster County District Court centers on state laws meant to prevent insurance providers (dental service plans, insurance carriers, self-funded employee benefit plans and prepaid limited health organization plans) from dictating the price of dental services they don't cover.

But the laws, passed in 2010 and 2012, don't include a definition for "covered service."

Which is where the dispute arose.

The Department of Insurance first provided a notice about its interpretation of the laws in 2014, allowing dental plans to use either of two definitions.

A covered service could be defined as when an insurer or plan covers any part of the dental provider's bill -- and a noncovered service when it doesn't, for instance because the patient has reached the maximum benefit for the year allowed by their plan.

Or, it could simply be defined as the services covered by a plan and noncovered services limited to those not covered under any circumstances.

In July, Ramge issued a bulletin sticking to the interpretation that it could be either.

"The department will continue to interpret (the laws) to allow either definition of 'covered services' until a definition is supplied by the Legislature or the courts," he said.

O'Doherty said for a while some insurance companies were abiding by the Dental Association's understanding of what senators intended in passing the law -- to keep insurance companies from forcing dentists to eat the cost of patients getting a higher-cost service than their plan provides.

But, he said, they've gotten more aggressive.

"It shows up in lots of different ways," O'Doherty said.

For instance, if a patient's dental plan covers the cost of a silver crown, but the patient wants one that's tooth-colored, which might cost the dentist $400 more to do, should the insurance company be able to cap the dentist from charging for more than a silver crown?

"That's the inequity of the issue that we're trying to address," O'Doherty said.

If a patient wants the Lexus-model instead of the Chevy, that's fine, he said. But they have to pay for it if their insurance doesn't cover it because it costs the dentist more. If patients don't like their plan coverage, they should talk to their employer about it.

In an 11-page complaint filed last week, Nathan Clark, an attorney representing the Nebraska Dental Association, asked a judge to declare the Department of Insurance's bulletin invalid and block them from enforcing it.

He alleges the department doesn't have the authority to cap a dental provider's fee to a patient for a service that the insurer or plan doesn't cover, "meaning a dental service for which the insurer or plan does not actually pay all or some part of the dental provider's charged fee for the service actually provided and identified by the dental provider."

Clark said Nebraska dentists are asking a judge to find that "dental services that are not covered" include services specifically identified in a policy or plan as noncovered or excluded, as well as those where the insurance company doesn't reimburse because of a contract limitation or exclusion, for instance a benefit maximum has been reached.

The state hasn't yet filed a response to the lawsuit.

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Reach the writer at 402-473-7237 or lpilger@journalstar.com.

On Twitter @LJSpilger.


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