by Christine Taxin
October 20th, 2014
Least Expensive Alternative Treatment Clause
What your patients do not know!
When alternate benefit or LEAT provisions are applied, they are not meant to dictate treatment, question professional judgment or interfere with doctor-patient relationships. The ultimate decision on treatment is up to the dentist and patient. The LEAT provision actually funds a range of treatment options within the reimbursement boundaries established by the employer group contract.
Alternate benefit or LEAT provisions are one component in maintaining dental coverage affordability. A core principal of insurance is the "law of large numbers," which means that there are predictable events with calculable costs over a large population. Identifying potential therapies for the incidences of disease and predicting costs is critical to maintaining the affordability of insurance benefits. Keeping benefits affordable expands access to dental care.
Most dental benefits are provided by employers through group coverage. More of the group dental benefits market is becoming voluntary. (Voluntary means the employer arranged for the group coverage but the employee pays the majority and often 100 percent of the premium.) Overall, most employers are decreasing contributions to employees' dental coverage.
Since dental benefits play an important role in enabling consumers to access dental care but consumers are paying more of the premium cost out-of-pocket, in addition to deductibles and co-payments, it is important to keep the cost of coverage affordable.
An alternate benefit provision in a dental plan contract allows the third-party payer or insurance carrier to determine the benefit based on an less expensive treatment could have been performed. It may be clearer to patients if the EOB could simply state what benefit the plan will allow. This difference may seem subtle, but patients sometimes misinterpret the wording "could have been performed" to mean "should have been performed." Regarding LEAT provisions, ADA policy also states "plans which contain this clause should make the limitations of this clause understood to the plan purchaser and the dental patient." The burden of explaining LEAT provisions in an EOB, in the least misleading manner possible, should be shared by the dental plan.
The risks and benefits of all treatment alternatives should be discussed with patients and understood to achieve informed consent. Ultimately, treatment decisions are made by the patient with cost as an important consideration. If dentists explain all aspects of proposed treatment, issues with LEAT provisions can be minimized.
Knowing the rules of insurance allows you to discuss in advance your treatment and what insurance will cover. Don’t make the error in allowing a patient to believe a crown is covered at 50% when they are only covering 50% of the lowest fee.
Same with composite filling (most offices do not even offer amalgam) but insurance will only pay for amalgam, you are allowed to bill up to the composite filling of the insurance plan.
Don’t let LEAT prevent you from collecting the copayments you are due!
Adjunct Professor of New York University
College of Dentistry
Tel (914) 303-6464 Ext 704