Some South Carolina dentists and oral surgeons say they are losing thousands of dollars in pay annually because of a state law.
State Sen. Ray Cleary, R-Georgetown and a longtime dentist, has filed a bill that he says will correct that, though he contends it won’t fatten his own wallet.
Under the bill (S. 136), oral surgeons and dentists licensed by the S.C. Board of Dentistry would be added to the definition of “emergency medical provider” under the state “Access to Emergency Medical Care Act.”
That law (Section 38-71-1530 of the S.C. Code of Laws) requires insurers, hospitals and other entities that operate a “managed care plan” to pay all emergency medical providers who treat an “emergency medical condition,” defined as any “condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in”:
- Placing the health of the individual, or with respect to a pregnant woman, the health of the woman or her unborn child, in serious jeopardy;
- Serious impairment to bodily functions; or
- Serious dysfunction of any bodily organ or part.
Cleary’s bill, which was filed last month, has been referred to the Senate Committee on Banking and Insurance. The General Assembly returns to Columbia Tuesday to start a new two-year legislative cycle.
Contacted Monday by The Nerve, Cleary, one of four listed dentists at Glenns Bay Dental Associates in Surfside Beach, said he introduced the bill after he was contacted by Dr. Jeffrey Wallen, a Myrtle Beach oral surgeon, who told him that some insurers were paying patients directly instead of him for emergency services he provided in hospitals.
“If they (insurers) pay for a physician or surgeon, they should pay for an oral surgeon,” he said, noting he is not an oral surgeon and doesn’t practice in hospital emergency rooms.
“I may pull a few teeth here and there, but I don’t set a jaw, and I don’t do anything in emergency rooms,” said Cleary, who has been a licensed general dentist since 1974, state records show.
When The Nerve pointed out, however, that his bill includes dentists and not just oral surgeons, Cleary said he added dentists to the definition of “emergency medical provider” because in rural counties, there often are no oral surgeons to provide emergency services at local hospitals.
The law doesn’t require that emergency services be performed in hospitals. It also generally requires that insurers “may not retrospectively deny or reduce payments to providers for emergency medical care” if it is “determined that the emergency medical condition initially presented is later identified through screening not to be an actual emergency.”
State ethics law (Section 8-13-700 of the S.C. Code of Laws) bans public officials from using their positions to “obtain an economic interest for himself, a family member, an individual with whom he is associated, or a business with which he is associated.”
But under a loophole in state law commonly referred to as the “large-class exception,” lawmakers can introduce bills that benefit their businesses if the legislation also would help other similar businesses equally.
The Nerve last week reported about three pharmacy-related bills filed in December by state Rep. Kit Spires, R-Lexington, who is a pharmacist and pharmacy owner. Spires denied he had any conflicts of interest in sponsoring the bills.
Contacted Tuesday by The Nerve, Wallen said he doesn’t believe it’s fair to him and other oral surgeons who provide emergency treatment to insured patients not to be paid by insurers while emergency-room physicians and surgeons who treat the same patients receive payments from those insurers.
“It’s been going on for a long time,” Wallen said. “I could probably retire early if that didn’t happen.”
As an example, Wallen cited the case of a young man around 18 to 20 years old who was seriously injured in a car accident and required emergency oral surgery. He said his bill for services was about $15,000, though the insurer paid $6,000 directly to the patient, who used the money to buy a car to replace the one totaled in the wreck. He added that a physician who also treated the young man was paid by the insurer.
Wallen said he believes some insurers are sending checks directly to patients to entice oral surgeons to join their health provider networks, which he noted usually results in lower, contractually obligated payments to providers. Insurers typically pay for what they consider to be “usual and customary” charges, he added.
As part of having hospital privileges, Wallen said he has to treat all patients, insured or uninsured, with emergencies, whether at the hospital or when the hospital sends patients to his office. Over the past year, he said he responded to 40 emergencies at one of two local hospitals where he has privileges, estimating he was paid a total of about 20 percent of the fees that he would normally charge.
Over last Memorial Day weekend when an annual popular motorcycle festival is held, Wallen said he treated seven facial fractures that resulted from motorcycle accidents or fights.
“He believes he lost $50,000 in (insurance) checks to people going back north,” Cleary said.
Wallen said Cleary, whom he noted he has known for 20 years and is one of the few lawmakers with a medical background, decided to draft the bill after contacting – but getting nowhere with – a large insurer on his behalf about the problem with dental payments.
It’s not the first dental bill that Cleary, who was first elected to the Senate in 2004 and is a member of the Senate Medical Affairs Committee, has sponsored. Last year, he was the author of a law that took effect Jan. 1, titled the “Dental Sedation Act,” which sets training and equipment requirements for different levels of sedation during dental procedures.
Cleary said he introduced the bill after learning about three sedation-related deaths in North Carolina. He denied it will benefit him personally.
“I have to put more money into it,” he said. “It will help the profession.”
Reach Brundrett at (803) 254-4411 or firstname.lastname@example.org. Follow him on Twitter @thenerve_rick. Follow The Nerve on Facebook and Twitter @thenervesc.