The issue of Medicare Advantage Plans and Avesis has been a topic of discussion for many months now. At one time, dentists were receiving letters that even though they did not participate in the network, they may not be able to balance bill above what the insurance company reimburses. Effectively, they were saying that by treating the patient you agree to their network without a contract. The ADA and the SCDA worked on the issue and originally thought that a dentist would be able to balance bill if you were not a participating network provider.   

Recently, the ADA issued a new opinion on June 6, 2011:

Avesis clarifies balance billing policy

By Kelly Soderlund, ADA News staff

The ADA Council on Dental Benefit Programs reports that new information has been provided regarding whether nonparticipating dentists can balance bill a patient for services rendered under Avesis, a national vision and dental company.

Avesis, which markets Care Improvement Plus, a Medicare Advantage plan, previously indicated it had no restriction on nonparticipating dentists balance billing patients. But upon further review of its terms and conditions, Avesis has clarified its position regarding balance billing.

The company indicates that if a dentist agrees to treat a patient who notifies them they are a member of the Medicare Private Fee-for-Service Plan, they also agree to Avesis's terms and conditions, thus entering them into a contract with the company and making it unallowable to balance bill patients.

The council originally became involved in the Avesis issue last winter when some dentists received a letter from the company regarding the Care Improvement Plus Program. Preliminary indications from Dr. Fred L. Sharpe, the chief dental officer from Avesis, implied that there was no restriction on balance billing Care Improvement Plus patients by nonparticipating dentists.

But Dr. Sharpe notified the ADA March 15 that the terms and conditions prohibited balance billing patients. Similar letters were sent to nonparticipating dentists March 1.

The dentist has the option to refuse to see patients enrolled in Medicare Advantage programs administered by Avesis. The ADA encourages dentists to consider their legal and ethical obligations when making such decisions.

Additional information on Medicare Advantage Plans can be found at:

http://www.mgma.com/policy/default.aspx?id=18732