THE EDITOR'S CORNER

How do you respond if an insurance company requests that you send them your diagnostic records on a patient? Do you send them models and x-rays? If your answer is yes, in my opinion you are doing the wrong thing, provided that you are not in the employ of the insurance company or have some other arrangement with them in which you agreed to supply them with diagnostic records. Until some law mandates cooperation of that kind with the health insurance carrier, there is no justification for the request for your records and ample reason not to set a precedent of that kind of compliance. The insurance company has no contract with the orthodontist and, while that lack of relationship exists, orthodontists will retain their independence of insurance companies. Anything that moves the orthodontist closer to the insurance company is a move toward insurance company control of orthodontic practice.

So, what do you do when you get a request for models and x-rays? You say, "No. I do not send my records out of the office."

Suppose they say, "Everybody else does"? You answer, "If that is so, everybody else is wrong."

Suppose they say, "Very well, suppose we send someone to your office to look at your records"? You say, "Absolutely not." There is no justification for such an intrusion into your office and it would be a bad mistake to invite them in.

Suppose they say, "Very well. If you will not send us the models and x-rays, we cannot authorize payment of benefits and your patient will lose out on his insurance cover age"? Then it is time to write the insurance company a letter stating: Your company is supplying benefits under a contract which my patient has with it. I am supplying services under a contract that my patient has with me. If there is a reason why the insurance company wishes to verify whether the patient qualifies for benefits under the terms of their contract with the company, the company must find means to do that directly with the patient. And, if the company would deny my patient benefits because of my refusal to send the company my records, then I think that my patient should take that up with the group of which he is a member. And, a copy of this letter is being sent to the patient.

As you may have surmised, this is a true story. The letter was sent. The copy was sent. The patient did take the matter up with the group and the group saw to it that the benefit was paid.

Now, one might well ask, "Is there a difference between sending models and x-rays and completing and filing claim forms?" The difference is a subtle, but most important one. The models and x-rays were refused to the insurance company. The claim forms were filled out for the patient, sent to the patient and filed with the insurance company by the patient.

Does that mean that it would be all right if the patient requested the models and x-rays and sent them to the insurance company? It would be better. On the other hand, the orthodontist owns the records by law and it is up to him to decide if he wants his records used in this way; if he wants to incur possible damage, loss, or extended absence from his office. Also, if the insurance company wants to establish whether a client qualifies under their contract, they can call in the client instead of the models.

It would be an error to establish a gratuitous relationship between the orthodontist and the insurance company with the direct passage of records or claim forms. It would be the beginning of accountability by the orthodontist to the insurance company. It would be equally unfortunate if the profession were to contemplate accepting payment from the insurance company for either records or claim forms. It seems logical to say, "All right. I'll cooperate with you. But, you will have to pay my fee for these services". If ever we agree to that, we accept an employer-employee relationship with the insurance company. Once you take their money, they own you.

That is why it is also not in our interest to agree to the apparent logic of direct payment of the patient's benefit to the doctor. It not only moves one step closer to that employer-employee status, but it alters the orthodontist's fee arrangement which is properly made with the patient and not related to the benefit.

Filing claim forms is an example of a bad precedent which, once established by acquiescence, becomes a generally accepted procedure even though the forms themselves are unsuitable, the information misleading and the filling out of the forms a gratuitous burden imposed on orthodontists by that precedent. Let us not compound one bad precedent with others such as the sending of diagnostic records to insurance companies or payment in any form directly from the insurance company to the orthodontist.