When you have a problem...
...with an insurance company not paying a dental claim, or if you are not happy with the dental care services you have received from a dentist, there are steps you can take toward a resolution.
Dispute resolution—ways for patients to handle a concern
If you have a concern, dispute, or complaint about dental care you have received or an insurance company not paying a dental claim, there are steps you can take toward resolving the issue.
The MDA suggests first approaching the dentist and/or insurance company to resolve an issue.
As a next resort, patients may use the MDA mediation process to resolve misunderstandings regarding the appropriateness or quality of care and, in certain instances, about the fees charged for dental treatment. However, we suggest patients first take the following steps to resolve disputes.
Talk to your dentist
Bring your issue to the attention of the dentist. The dentist or office manager should be able to address your issue. Simply bring it to the practitioner’s attention by calling the office.
If you do not wish to discuss the dispute or “confront” the dentist, send your complaint in writing—certified mail or by facsimile will guarantee receipt. When you contact the dentist, make sure you are prepared to discuss:
• the involved date-of-service (treatment date)
• dollar amount in dispute
• your issue, and
• an outcome that will make you happy.
By contacting the dentist with your issue before going through other grievance processes, you will likely resolve your issue quickly.
Contact your insurance carrier
If your issue involves an HMO, health insurance company, or a contracted provider (chosen from a list from the insurance company), contact the customer or member services department of the insurance company for assistance in resolving an issue or explaining coverage.
If the member services representative does not help resolve your issue to your satisfaction, ask to file a “first step” grievance—this may be called an appeal, a reconsideration, complaint, or grievance. There is usually a multi-step approach to handling insurance complaints.
Only your insurance company can address insurance benefit coverage or billing issues. It is the patient’s responsibility to know what his/her insurance coverage and benefits are, even if the dentist’s office indicates a certain coverage will be provided. Each dentist’s office works with several insurance companies and cannot know what each patient’s coverage provides.
If a patient’s complaint meets the MDA peer review criteria, he or she may call the MDA office at 601-664-9691 for assistance through the peer review process. Steps of the process are as follows:
• The patient receives forms to complete and return to the MDA Central Office in Jackson.
• The forms are reviewed to see if the issue meets the peer review criteria.
• The forms then will be sent to a local district dental society for consideration by a panel of dentists.
A mediation trained dentist will contact the involved parties and make every attempt to help the patient and dentist reach a mutually satisfactory resolution. If mediation is not successful, the case proceeds to a committee hearing where a panel of dentists will present findings and recommendations for a resolution. This process is non-binding and voluntary and is provided under Mississippi state law code.
It is always best to have your facts ready before you file a complaint. Make sure you have:
• the date-of-service (treatment or service date in the doctor’s office)
• any involved follow-up dates
• copies of receipts and agreements
• copies of treatment plans, financial arrangements, records, etc.
DO NOT SEND ORIGINALS. Briefly describe the issue or dispute. Suggest a resolution that would be fair and satisfy you. Be courteous and calm.
If you have any questions about resolving disputes, please contact the MDA.