Insurance Management FAQs

My patient is involved in an auto accident requiring dental services. Which insurance carrier is responsible for covering the injuries incurred in an auto accident?

Act 6 limits the amount of payment that may be received by a health care provider in treating an injured automobile insurance policyholder. The health care provider must accept payment from the patient’s auto insurance company as payment in full. The provider may not balance bill the patient for the remaining balance.

The fee schedule that is used to determine the reimbursement level is that of the Medicare Fee Schedule. If the charges that occur cannot be calculated under Medicare, payment is not to exceed 80 percent of the provider's usual and customary charges. Charges for services must be billed directly to the insurer and not the insured.

The provisions of Act 6 are applicable in all cases where services are rendered by a provider licensed by the Commonwealth of Pennsylvania.

Should auto insurance benefits be completely exhausted and no portion of the provider’s bill be payable under auto insurance coverage, Act 6’s payment limits are no longer applicable to payment. In this case, the provider may either bill the patient directly, or bill the secondary insurer.

Example I: Assume an insurer’s auto insurance limits have not been exhausted ($5,000 medical benefits) and the auto insurer receives a provider’s bill of $13,000 that is reduced to $7,000 when factoring Medicare reimbursement rate. The bill still exceeds the auto policy limits by $2,000. Since there is no applicable secondary insurance, the provider may bill the patient for the difference between the Medicare reimbursement rate ($7,000) and the policy limits ($5,000). Therefore, the patient can be billed $2,000 in this case.

Example II: In the case above, if coverage were available from a secondary insurer, the provider may bill the secondary insurer for the full remaining balance of $8,000 ($13,000 charge less $5,000 policy limit). The secondary insurer will determine the appropriate amount of payment to the provider under the terms of the patient’s policy.

Answer is informational only and not intended as legal advice. Answer may contain excerpts from
The ADA Practical Guide to Frequently Asked Legal Questions.