Dr. O's Dental Consultant Coding Info
Wickline and Wilson Cases
What is it?
- Some dentists have a narrative that they submit with dental insurance claims that mention "Wickline and Wilson Cases".
What does the narrative say?
- The most common one contains this wording: "This letter will also serve as formal notice, per the Wickline and Wilson Cases of our responsibility advocating the appropriate treatment for this patient. Should this patient have suffered future damages as a result of an inappropriate insurance denial, the insurance company would be held responsible for any damages."
Why is this done?
- In hopes of increasing reimbursement from the dental insurance company.
When is this done?
- Some offices include it with any claim that includes a separate narrative.
- Some offices include it only with claims that are being appealed.
- Some offices include it only with claims that are for procedures that might not normally be contractual benefits on a patient's insurance plan, or might be assigned a lower alternate benefit.
What is the problem?
- Most dental offices that use this reference in their narrative do not understand it, and are using it only because a lecturer mentioned it, or they heard of a colleague using it.
- If a dental office chooses to reference the Wickline and Wilson cases, they should be able to explain why they are referencing the cases, and be able to explain how those legal cases apply to the submitted dental claim.
Where did it start?
- Possibly started from a lecturer for Cerec.
What are the Wickline and Wilson Cases?
- These were two medical lawsuits filed against third party payors by a patient or patient's parents.
- In both cases the courts commented that ultimately the discharge decisions are the responsibility of the physician.
- The attending physicians were not sued in either case. The courts in both cases intimated that had the physicians been sued in either case, the judgments might not have been favorable to the physicians.
Summary of Wickline case:
- In 1986, Wickline sued California Medicaid program, alleging premature discharge from hospital following vascular surgery. Wickline had numerous post-op complications, resulting in amputation of her leg. Wickline won the lawsuit, but the verdict was reversed in the California Court of Appeals. The Court of Appeals commented that ultimately the attending physician makes the decision to discharge a patient, and that the third party payor cannot be held liable for poor judgment on the physician's part.
Summary of Wilson case:
- In 1990, Wilson was admitted for mental illness and drug dependency problems. His physician recommended 3 to 4 weeks of inpatient care. He was discharged after 10 days due to nonauthorization of inpatient care. Wilson committed suicide three weeks after his discharge. Wilson's parents sued Blue Cross, claiming that they were responsible for his death due to their conclusion that he did not meet inpatient admission criteria. Blue Cross was found not guilty. The Court of Appeals reversed the judgment, commenting that physicians are not solely responsible for treatment decisions when a utilization review company is involved, and that the HMO may be held liable for decisions based on finances.
Will this help a submitted claim to be paid?
- Extremely unlikely. Dental insurance companies are very familiar with this narrative, and are also very familiar with the two court cases referenced. They know how the cases might or might not be applicable to dental claims in general. And in almost all dental claims situations, these cases are simply not applicable.
Will this be detrimental to a submitted claim?
- Maybe. Mayby not. It might make the claim stand out from other claims, which generally results in the claim getting more attention; a red flag. This could have positive or negative results, depending on all the other information presented in the claim.
- Legal summaries and analysis of Wilson case.
- Legal summaries and analysis of Wickline case.
- Discussion with licensed dentists who work in the dental insurance industry.