ADA, Member Dentists Sue Health Insurers

The American Dental Association (ADA) and two of its member dentists are suing some of the nation’s largest insurers under the federal Racketeer Influenced and Corrupt Organization Act (RICO) and supporting state laws for insurance abuses against dentists contracted under the insurers’ managed-care plans.

Defendants named in the lawsuit are CIGNA Corporation, CIGNA Dental Health, Inc.; MetLife, Inc.; Metropolitan Life Insurance Company; Connecticut General Life Insurance Company; and Mutual of Omaha Insurance Company.

The class-action lawsuit, filed in the U.S. District Court, Southern District of Florida in Miami, charges the defendants with illegally paying their in-network dental providers less than their charges for provided dental services and with late payments in states with prompt-pay statutes.

Specific charges in the complaint include the defendants’ secret use of cost-based or other actuarial criteria unrelated to a covered procedure or service to approve or deny claims.

The defendants also are charged with allegedly downcoding (changing the procedure code to a less expensive code) and bundling (combining codes of two or more performed procedures into one billed procedure) to deprive plaintiffs of fees owed to them for covered services.

Further, they allegedly intentionally engaged in delaying payments to dentists, including the use of automated programs that suspend claims before actual processing and used their economic power and market dominance to coerce plaintiffs to accept these abusive practices and to unilaterally amend contracts with dental providers.

The complaint also alleges the defendants engaged in a conspiracy to undertake these abuses with third parties, including other managed care and dental insurance companies, trade organizations and vendors.

“We are disturbed by these practices and intend to pursue vigorously all of our legal remedies for the benefit of our members and their patients,” said ADA President T. Howard Jones, D.M.D.

The plaintiffs seek an injunction to prohibit the insurers from continuing to engage in the alleged abusive behaviors and awarding of compensatory and punitive damages.

“The conduct that we have found with reference to the defendants in this lawsuit is pervasive, unfair to patients and the profession, and, I believe, illegal” said Peter Sfikas, ADA chief counsel. “These are matters that should be brought to the attention of the federal courts and rectified there.”