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.
Antitrust Laws and Dentists
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.
PPO Contract Provisions:
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.
At Unitas, we are an extension of our client’s dental practice for the purpose of obtaining PPO insurance participation and insurance reimbursement information. We keep all of our client’s information confidential and separate. We do not and will not share any specific information between our clients or with any other person/entity who contacts us, unless our client has given us authorization to do so, and doing so complies with antitrust laws and the terms of our client’s PPO insurance contracts
(1.) “The Antitrust Laws.” Federal Trade Commission. N.p, n.d. Web. (www.ftc.com) 01 Dec. 2016.