Usual and Customary UnitedHealthcare?

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More on “Sleazy” Healthcare Stakeholders


[By Darrell K. Pruitt; DDS]

If the leaders of the American Dental Association have the power and stoic determination to casually sweep aside trouble-making members who might tarnish their image, one would think that they could certainly avoid associating with sleazy healthcare stakeholders; such as UnitedHealthcare.

The Insurance Giants 

Have you ever suspected that insurance giants like UnitedHealthcare, WellPoint, Aetna and Cigna (and other members of the National Association of Dental Plans) lie to patients when the say a dentist’s fees are above “usual, customary and reasonable” levels?  You could be correct.  NY Attorney General Andrew Cuomo says UnitedHealthcare, WellPoint, Aetna and Cigna lie to physicians’ patients – understating New York state physician’s fees up to 28 percent.  Why would the crooks treat dentists’ patients any differently?

Employing Tapeworms to Control Fat

Cuomo caught UHC and others cheating their customers with smoke, mirrors and Ingenix – its wholly-owned data mining and consulting subsidiary.  Who would have guessed that UHC would tweak Ingenix to manipulate claims data to favor UHC and other insurance companies who subscribe to their services?  These are the same parasites who want to run the nation’s Pay-For-Performance (P4P) mandate – a cornerstone of President Bush’s healthcare reform ideas.  They want to tweak professional reputations for healthcare reform and the common good. 

And of Ingenix 

Ingenix is a full-service consulting business for insurers, backed with the credibility of 14 years of accumulated health claims it is privy to.  The “friend in the business” not only cooks the data to produce profit-enhancing Usual, Customary and Reasonable (UCR) fee schedules, Ingenix is also active in “pay-for-performance program assessment, strategy, planning, design, implementation, evaluation and improvement.”

So if you like the way UnitedHealthcare dental consultants treat you now, just wait until they are given authority to determine your worth to society using Ingenix leveraging tools.


I first read about pay-for-performance [P4P] in dentistry in February 2006 in an email from Patrick Cannady who is an employee in the ADA Department of Dental Informatics.  He told me that nation-wide quality control in dentistry is an important benefit of having a HIPAA-compliant, paperless dental practice – and that the Department of Dental Informatics is very excited about the opportunity to help prepare US dentists for the future.  A month or so later, I learned that the NPI number the ADA still pushes on membership is the crucial legal link to government-approved P4P data-mills like Ingenix – a wholly-owned UnitedHealthcare profit center.  Do you think it is odd that the NPI is “voluntary,” yet irreversible?

AMA’s Award 

In January, the AMA was awarded $350 million in a lawsuit against UnitedHealthcare and Ingenix on behalf of physicians, and they plan to sue other major insurance companies as well.  So what has the ADA done to discourage UnitedHealthcare’s and other NADP members’ atrocious behavior that undeniably harms dental patients?  You won’t believe it when I tell you. Here’s more:  In a recent Associated Press interview, Sen. Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee, said UnitedHealthcare is nothing but a company of cheats.  He says, “They’re lowballing deliberately. They deliberately cut the numbers so the consumer has to pay more of the cost.”

So if Cannady’s department is all for P4P and other benefits from interoperable digital records, the question on most ADA members’ minds should be:  What does the ADA think of UnitedHealthcare?

ADA News Online

Two weeks ago the ADA News Online posted an advertisement that looks like an article (with no byline) for the spring meeting of the American Association of Dental Consultants (AADC) on May 7-9 in Scottsdale, Arizona.

Since it is so well known that UnitedHealthcare is the major funding sponsor of the AADC, the word in the neighborhood says AADC, like Ingenix, is another UnitedHealthcare profit center awaiting the wrecking-ball.



Last year’s annual meeting of the dental consultants – who deny dental claims to protect the ethics in dentistry – featured ADA Senior Vice-President Dr. John Luther as a guest speaker.  Dr. Luther is Cannady’s boss.  He oversees the Department of Dental Informatics.  Yep.  The ADA is tight with UnitedHealthcare. One can tell a person’s character by the company he or she keeps. 


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3 Responses

  1. Carbon – The underappreciated element in dental history

    Here is a chunk of non-intuitive information for dentists who are much younger than I am. Dr. Carbon did not invent “carbon paper” as a means to determine how well a restoration hits against opposing teeth. It was invented in an Iowa dental practice in 1958 by clever office manager named Julia Carbon to make the brand new pegboard system of accounting go much faster.

    Techies won’t like the bad news I found today on Neither will dentists who have simply grown accustomed to having computers in their business offices.

    Eventually, an officer in the ADA Department of Dental Informatics will have to admit that it is possible to reach a level of bureaucracy-enforced micromanagement that will return dentists to pegboards, ledger cards and lots of carbon paper.

    Worse things could happen. We could be required by federal law to maintain digital records, be HIPAA-covered entities and have NPI numbers.

    How badly do you want decisions between you and your patients to be second-guessed by an algorithm machine like UnitedHealth’s Ingenix or the rating contraption that BCBSTX unsuccessfully tried to roll by Texas Attorney General Greg Abbott? Other than an enthusiastic slip-up by the ADA informatics department’s rep Patrick Cannady in an email to me three years ago, the ADA has still not informed membership that HIPAA is about control, not privacy. Nobody in the ADA talks with members about HIPAA any more, not even with talking points … and those were so cute.

    As an ADA member, I want to know when ADA officers first recognized that the 2003 amendments made to the 1996 HIPAA Rule turned it into a Trojan horse infested with parasites. Were the leaders that dentists absent-mindedly elected, privy to the intentions of the Bush administration before or after Newt Gingrich’s visit to ADA Headquarters. I’m looking for signs of a trail to the origin of accountability so that this blunder will not happen again.

    It is my opinion that the ADA is under siege over HIPAA, and will hold out as long as possible to relate the bad news that you can read below. I challenge Dr. John S. Findley to tell me I’m wrong – not in hushed tones just to confused and anxious buddies, but right here in front of everyone. That would take confidence I could admire forever.

    D. Kellus Pruitt DDS


    CMS Keeping Tabs on HIPAA Violations

    The Centers for Medicare and Medicaid Services (CMS) published a notice describing a new records system designed to store the results of regional investigations into complaints alleging violations of HIPAA’s transactions and code sets, security and unique identifier provisions, AHA News Now reported.

    The Office of E-Health Standards and Services (OESS) is charged with overseeing compliance in those areas. OESS has procured a contractor to maintain the database, according to the notice.

    Authorized under HIPAA, the HIPAA Information Tracking System will store data on complaint allegations, information gathered during complaint investigations, and findings and results of investigations, CMS reported. The notice described proposed policies, procedures and restrictions on disclosures of data, and invited comments on the records system.

    The notice, which specifies instances in which the government will disclose information stored in the database, is available at:


  2. UHC

    Federal Appeals Court Sides with Out-Of-Network Doctors Against UnitedHealth.

    Any thoughts?

    Dr. David E. Marcinko MBA


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