By David Burger
From the Winter 2018 Journal of the Colorado Dental Association
Dentists have many concerns when it comes to their patients’ dental plans, benefits and third-party payers.
Among them are pre-authorizations, delays in processing claims, claim denials, refund requests and the lack of assignment of benefits to non-participating dentists.
Staff of the ADA Center for Dental Benefits, Coding and Quality within the Practice Institute continually receive and address a variety of dental claim submission and adjudication questions from member dentists and practice staff. While many times there are unique concerns, there are often similar questions—which the staff is happy to answer.
The Center for Dental Benefits, Coding and Quality staff has come up with a list of the top five concerns of dentists when it comes to dental benefits, based on calls received from dentists and their staff.
What follows is a brief description of the top five concerns, along with some resources that member dentists can turn to for further help in those areas. Many of the resources are located at the ADA’s one-stop shop on dental benefits, part of the ADA Center for Professional Success.
The top five concerns, in no particular order, are:
- Provider contract issues. If a dentist has contracted with a third-party payer, he or she may have agreed to abide by the carrier’s processing policies. Often dentists may not be aware of these policies and procedures, and sometimes, the payer may not release detailed information related to the carrier’s policies and procedures until the dentist becomes a participating provider. This, of course, may make it difficult for the dentist to have a clear understanding of his or her contractual obligations. The ADA Contract Analysis Service was created in 1987 and is a part of the ADA Division of Legal Affairs. The service is available free of charge to members who request a review through their constituent dental society.
- Claim rejection. Many questions have centered around four CDT codes that frequently prompt claim denials: D4341 and D4342 for periodontal scaling and root planing; D4910 for periodontal maintenance; and D2950 for core buildups, including any pins. The Council on Dental Benefit Programs, recognizing the need to further educate dentists and dental offices on the proper way to handle and respond to claim rejections from third-party payers, has developed a written policy for members called Responding to Claim Rejection. “I know that many dental offices do not take the time to appeal denied claims, and that’s unfortunate,” said Dr. Steve Snyder, the council’s chair. “My recommendation is that if you have a claim that you think should be paid, take the time to teach your staff on how to file a proper appeal. It’s an easy task, and the ADA has information on how to file a proper appeal. You’ll be helping your patients get the benefits for which they’ve been paying. In fact, the Center for Professional Success offers a plethora of valuable information that the council has developed to help dental offices cope with the many aspects of dental benefits issues reported to the ADA by member dentists.”
- The related trio of bundling, downcoding and the least expensive alternative treatment clause. Bundling is defined by the ADA as the systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient. Downcoding is defined by the ADA as a practice of third-party payers in which the benefit code has been changed to a less complex (i.e., lower-cost) procedure than was reported except where delineated in contract agreements. And the least expensive alternative treatment clause—also known as LEAT—is a type of cost containment measure used by many third-party payers when there are multiple viable options of treatment available for a specific condition, but the plan will only pay for the least expensive treatment alternative. “In these cases, it is also appropriate to appeal the benefit decision if you think the claim has not been properly adjudicated,” said Dr. Brett Kessler, chair of the council’s Dental Benefit Information Subcommittee and a past president of the Colorado Dental Association. “You should consider including the following documentation when sending the carrier a written request to reconsider the claim: a narrative description providing as much information as possible, including radiographs, clinical photographs, charting and/or study models.” For more information, visit Responding to Claim Rejections.
- Coordination of benefits. The ADA policy is based on the premise that the patient should get the maximum allowable benefit from each plan. In total, the benefit should be more than that offered by any of the plans individually but not such that the patient receives more than the total charges for the dental services received. “Increasingly, the ADA receives calls from dentists who want to know which plan is primary and want to know why the secondary carrier refused to pay or paid very little,” said Dr. Snyder. “Calls on coordination of benefits are some of the most frequent calls staff at the ADA receive on dental benefits issues.” For more information, visit “ADA Guidance on Coordination of Benefits.”
- Electronic fund transfers. The switch to electronic reimbursement by some third-party payers has prompted the ADA Practice Institute to study how easily dentists could make the change in their offices. “The ADA recognizes that electronic funds transfer, though, is on the road to becoming the preferred payment method of the future,” said Dr. Mark Mihalo, chair of the council’s Subcommittee on Coding and Transactions. A white paper based on a study of dentists making the change to electronic fund transfer payments is expected to be released in December, and the ADA News will report the results to help dentists make the eventual switch. In the meantime, the ADA has a recorded webinar on electronic fund transfers—addressing the how, the why and the myth. “For those members whose practices are not equipped to handle electronic fund transfers, or do not wish to accept payment via debit card, we have ensured that individual dentists may opt-out and continue to receive paper checks for their claim reimbursements,” said Dr. Mihalo.
Staff from the Center for Dental Benefits, Coding and Quality can help dentists with their insurance-related problems, questions and concerns. Staff can be reached at 800-621-8099.
If dentists wish to alert the ADA to a concern, they can complete the downloadable form on ADA.org titled Third-Party Payer Complaint Form, which gives dental offices the opportunity to provide ADA information on the problems experienced with third-party payers. The Council on Dental Benefit Programs developed the form to track industry trends and facilitate discussions with individual insurance carriers and benefit plan providers.
If dentists have a concern or question they would like addressed in a future issue of the ADA News, they can contact email@example.com.
Burger D. Decoding Dental Benefits: The top 5 concerns of dentists. ADA News. Posted online November 10, 2017. Copyright © 2017 American Dental Association. All rights reserved. Reprinted with permission.