February 22, 2011
What are non-covered services? Why do they matter to me?
Recently, you’ve probably heard a lot of buzz about a “non-covered services bill” – a bill that would stop dental insurers from setting fees for services and procedures that they do not cover under a patient’s plan. You may be wondering what this is about, and why the CDA is spending so much time and energy on this issue.
What are non-covered services?
A number of dental plans have amended their contracts with participating dentists to require you, the dentist, to discount your fees for services that the plan doesn’t pay for. Dental plans like Delta Dental, United, and others are requiring you to adhere to their fee schedule even though premiums weren’t paid to cover these non-covered services, and the dental plan doesn’t pay you a dime for them. Oftentimes, the allowed fee for non-covered services does not even cover the dentist’s hard costs in providing the service. Depending on the patient’s plan, this policy can impact a variety of services – ranging from teeth whitening to implants to orthodontics and more.
Adverse Impacts for Your Dental Practice
- When a business is forced to provide a discount on a service, they are also forced to make a business decision on where those costs will be made up in order to stay in business. Forcing a business to discount its fees for non-covered services does not reduce actual costs, it just shifts them. That could mean putting off the purchase of equipment that would benefit patients or cutting back on employee hours. National estimates project that $1.7 billion of costs would be shifted from the insurer to the dentist in aggregate as a result of this insurance policy.
- Discount dental plans are on the rise. Discount plans offer minimal benefits such as an examination, a few x-rays and a cleaning or two for a very low premium. Under discount dental plans, the plan’s fee schedule (discounts) applies to all other services the patient receives, even though the patient didn’t pay premiums to receive these dental services. As the number of these plans increase, an increasing percentage of the services you provide will be non-covered services. This situation could have an adverse impact on the viability of dental practices, the ability to serve patients and the quality of care.
- The essence of any contract is a fair exchange of benefits for both parties. In this situation, insurers and dentists are not on a level playing field. The insurer assumes no risk as it mandates a fee schedule for non-covered services; however, the dentist is forced to absorb all the risk and costs associated with this discount. This is not a fair exchange of benefits. In a fair contracting environment, this type of contract provision would not be accepted by dentists. However, the leading insurer in implementing this policy has such a large market share – essentially a monopoly – that dentists do not have the ability to object to or refuse the contract amendment. Further, fee schedules are not disclosed to dentists so they can accurately assess whether continued participation in the network is financially viable for the practice.
Adverse Impacts for Your Patients
- These insurance policies can create barriers to care, where the insurer essentially dictates the treatment that can be accessed. Because fee schedules are usually designed with the economy service or procedure in mind, the insurance policy can restrict patients from choosing higher quality products (like name brand mouth guards or more durable implants) even though the insurer isn’t even paying for the care. It can also disrupt the dentist-patient relationship if the nature of the fee schedule makes a referral to a non-network dentist the only option for attaining the treatment that the patient desires.
What Can I Do to Help?
The CDA has worked with the state legislature on a bill to prohibit Colorado dental plans from setting fees for non-covered services, given the impacts these policies have for members’ patients and businesses.
You can help educate your legislator about this issue by: calling or e-mailing your state legislators and asking for their support, coming to the state Capitol with the CDA to talk to legislators, attending bill hearings and more. Be sure to check your e-mail and the CDA Website for details on how to get involved in these activities.
How Likely is this Bill to Pass?
It won’t be easy. The CDA is battling the state’s major insurance companies on this issue. However, we have something they don’t – we have YOU – a membership that is 3,000+ strong. With your active support, we know we can win this.
Member involvement at the local level has been key to the passage of similar legislation in other states. When legislation was up for a committee vote in Virginia, 300 dentists turned out for a hearing! We must replicate that kind of grassroots activity here. Direct contact with your local lawmakers – in person, by phone or via e-mail – is critical to our success. Lawmakers are well aware that dentists vote; if you contact them, they will listen. To find out how to contact your legislator, go to cdaonline.org/actnow.