CASE STUDIES OF THE ODA HELPING MEMBER DENTISTS GET REIMBURSED FOR THEIR SERVICES WHILE ALSO HELPING DENTISTS KEEP THE MONEY THEY’VE EARNED
Most dentists agree that dental insurance is a mixed bag. On one hand, dental insurance plans typically encourage preventive care, assist patients in paying for dental services that they might not otherwise agree to accept and offer the prospect of channeling new patients to dentists. On the other hand, however, reimbursement rates often do not maintain pace with the rising cost of running a dental practice, limit the total amount dentists may collect for their services, increase the dental office’s administrative burden and limit treatment options from either the patient’s or dentist’s perspective, or both.
The negatives associated with dental insurance cause aggravation and problems for dentists and their practices on many levels. They’ve also proven to be areas where the Ohio Dental Association has provided value to the profession on both an individual and collective level.
Legislative and regulatory advocacy
Years of legislative advocacy by the ODA’s elected leadership, lobbying team and grassroots dentists resulted in the passage of Ohio’s non-covered services law. The law, which took effect on Jan. 1, 2025, prevents insurance companies from requiring a dentist to accept an insurance company determined fee for services the plan does not cover, thereby freeing the dentist to charge their usual fee for non-covered services. Passage of the law has enabled patients and dentists to have a fuller choice of treatment options to best meet the patient’s oral health care needs. At the same time, according to reports from dentists to the ODA, the new law has resulted in dentists receiving annual estimates of around $1,000 to tens of thousands in increased income but no reports of dental fees going up as a result of the law.
While the dental insurance industry has done a good overall job of implementing the non-covered services law in a dentist friendly manner over the past 18 months, the ODA did identify two instances where major dental insurers incorrectly interpreted the law in the ODA’s opinion. One case involved how a company handled claims for adult fluoride treatment and the other involved claims for nitrous oxide. In both cases, the ODA went to the carriers and were able to get the insurers to change their positions and handle the relevant claims as non-covered services, thereby allowing contracting dentists to bill and collect their usual fee instead of the discounted fee.
Another significant legislative victory that positively impacted access to care and dentists’ ability to provide care occurred when the 135th General Assembly adopted a state operating budget that included an historic Medicaid dental fee increase of an average of 93%. Like the non-covered services bill, the Medicaid fee increase came as a result of advocacy efforts of the ODA’s elected leadership, lobbying team, grassroots dentists and other stakeholders. Advocacy with state Medicaid officials also ensured that 100% of the money allocated by the legislature went toward dental care, i.e., dental fees, and none went to administrative costs. The fee increase, which took effect on Jan. 1, 2024, was preserved in the current state operating budget through continued advocacy efforts. Nearly doubling fees has significantly benefited dentists’ bottom line. The fee increase has also led to more patients receiving care through the Medicaid program, more dentists becoming Medicaid providers and more care being delivered by dentists who were Medicaid providers prior to the fee increase.
When one of Ohio’s Medicaid HMOs failed to pay dentists the required 5% “bonus” for providing care to Medicaid covered patients in Ohio’s rural counties in early 2025, the ODA stepped in and worked with the HMO to get the payment situation fixed. Affected dentists were all made whole without having to resubmit any claims that were previously paid at an incorrect lower rate.
In 2023, the Ohio Department of Medicaid (ODM) enacted a claims processing policy change that inadvertently cost dentists half of their typical reimbursement amounts. The policy involved Ohio Medicaid fee-for-service program claims for multiple surgical procedures (e.g., extractions, alveoloplasties) provided to the same patient on the same date of service. It was driven by data and information supplied to ODM by the Centers for Medicare and Medicaid Services (CMS), the federal agency that, among other things, oversees the administration of the country’s Medicaid program by the states. The resulting reimbursement cuts to Ohio dentists were unanticipated and unknown to ODM until the ODA identified the problem and brought the matter to ODM’s attention. Relationships that ODA staff and volunteer dentist leaders had developed over the years with ODM staff led to a successful and timely fix to the claims processing problem. All of the affected dentists were made whole with the correct reimbursement amounts without having to resubmit any claims or take any type of action on their own.
The ODA expressed its concerns to a dental insurer in 2024 concerning its requirement that “post-operative radiograph(s) showing the delivery of the crown must be included with claim submission for payment.” As a result of the ODA’s intervention, the insurance company worked with the ODA to develop a mutually agreeable resolution to not require a post treatment X-ray if the dentist deems it not appropriate to take a post treatment radiograph and will instead accept an alternative proof of liability like a photograph.
The ODA’s for-profit subsidiary, ODA Services Corp., has endorsed DentalHQ to assist member dentists in creating in-office dental or membership plans. The service provides dentists with a turnkey, user-friendly platform for creating and managing direct-to-patient in-office membership plans to bypass traditional insurance restrictions, secure predictable recurring revenue and offer affordable care to uninsured patients. DentalHQ reports its membership plan platform helps dentists boost patient retention by 90%, treatment acceptance by 25% and offers the prospect of six figure revenue within 12 months. To learn more, sign up for a free web demo, and enroll in the ODA Services Corp. in-office membership plan powered by DentalHQ, visit www.dentalhq.com/ohio. ODA members receive discounts off DentalHQ’s monthly and management fees along with a 45-day free trial and no set up fees.
The dental association continues to offer the Contract Analysis Service as a no-cost service that aids member dentists in understanding the terms and obligations of contractual agreements with dental insurers. It takes contract legalese and translates it into easy-to-understand language and identifies potentially problematic contract provisions and their possible impact on the dental practice. This information can help the dentist either negotiate more favorable contract terms or at least have a fuller understanding of what to expect as a result of entering into the agreement. To utilize the Contract Analysis Service, ODA members simply have to contact the ODA Department of Dental Services (800-282-1526 or dentist@oda.org) and request an analysis of the contract they are considering. If the contract has already been analyzed, then its analysis will be sent to the member at no charge. If the contract has not been previously submitted to the ODA for review, then the dentist will be asked to send the ODA an unsigned copy of the contract and any accompanying documents. The ODA will then forward it to the American Dental Association where the ADA’s attorneys will analyze it. The ADA will return the completed analysis to the ODA, which will then provide it to the member dentist, again at no charge.
Moving forward, the ODA is supporting three dental insurance reform legislative initiatives, House Bill 429, House Bill 845 and Senate Bill 162.
HB 429 would prohibit health and dental insurers from “bundling” and/or “downcoding” insurance claims submitted by dentists and other health care providers. It was introduced by State Rep. Jim Hoops (R-Napoleon) and is currently pending in the Insurance Committee of the Ohio House of Representatives.
HB 845 would build more transparency into the dentist-insurance relationship by prohibiting: 1) companies from leasing their dental provider networks to other plans without first obtaining the participating dentist’s consent, 2) dental insurers from denying payment of a claim that the insurer previously authorized and 3) dental insurers from requiring dentists to accept virtual credit card payments without the dentist’s consent. It was introduced by State Rep. Meredith Craig (R-Smithville) and is currently pending in the Insurance Committee of the Ohio House of Representatives.
Senate Bill 162 would tighten the time frame an insurer has to initiate the recovery process for overpayments from two years to one year. SB 162 is sponsored by Sen. Louis W. Blessing (R-Cincinnati) and has passed the Ohio Senate and is pending in the House Health Committee.
HB 429 and HB 845 were two of the priority issues that dentists who participated in the ODA Day at the Statehouse on May 20 discussed with their state senators and representatives.
Advocacy for individual ODA member dentists
Nearly 500 member dentists turn to the ODA each year to get their dental insurance questions answered or to seek assistance when they find themselves unable to resolve problems with dental insurance companies or other third-party payers on their own.
In 2022, many Ohio dentists were assessed “negative incentive amounts” (which many would also call financial penalties) through ODM’s Episodes of Care program. The program was described as an episode-based payment program as “part of quality-driven payment innovation” that sought “to reduce health care costs and improve quality of care by providing transparency on spend and quality across an entire episode, allowing providers new visibility into their performance and how they compare to peers.” While well-intentioned, the program had an unintended negative impact on many dentists. The ODA responded by working with the member dentists who contacted the ODA, communicating behind the scenes with ODM staff and filing a formal complaint with ODM. ODM in turn acted in a favorable way to the ODA’s requests by taking definitive steps to set matters right. Affected dentists were given an easy to implement and well communicated way of appealing their initial adverse determinations. As a result, the numerous ODA members who were impacted reported to the ODA that their appeals were successful and that they no longer had to repay any money. While hundreds of dentists across the state were likely positively impacted by the ODA’s intervention and ODM’s willingness to address the problem, the ODA received reports from the following:
- An Akron area dentist reported the elimination of having to pay $12,939.92.
- A Canton dentist reported the elimination of having to pay an undisclosed amount.
- A Central Ohio dentist reported the elimination of having to pay $2,623.60.
- A Central Ohio dentist reported the elimination of having to pay $2,357.50.
- A Cincinnati area dentist reported the elimination of having to pay $9,573.50.
- A Columbus dentist reported the elimination of having to pay $64,872.02.
- A Columbus dentist reported the elimination of having to pay $57,396.91.
- A multi-dentist Columbus dental practice reported the elimination of having to pay an undisclosed amount.
- A Greater Cleveland area dentist reported the elimination of having to pay $40,000.
- A Greater Cleveland area dentist reported the elimination of having to pay $141.40.
- A North Central Ohio dentist reported the elimination of having to pay nearly $70,000.
- A Youngstown area dentist reported the elimination of having to pay $6,679.46.
Last year, a Toledo area dentist encountered difficulties in getting revalidated as a Medicaid provider by ODM. Despite her best efforts, the dentist could not get revalidated and was unable to see any patients covered by Medicaid. With Medicaid reimbursement comprising 90% of her practice’s income, the dentist was on the verge of having to close her multi-location practice and let go of all her employees. ODA staff utilized professional contacts within ODM that have been developed over the years to get the dentist’s situation into the hands of the correct officials who, within four days of the dentist’s initial contact to the ODA, reinstated the dentist as a Medicaid provider in good standing.
Earlier this year, another ODA member encountered recredentialling problems with one of Ohio’s Medicaid HMOs. He was disenrolled from the plan’s network of dentists and was required to pay a $1,500 fee in order for his reinstatement application to be considered. ODA staff utilized professional contacts within the HMO and its dental administrator that have been developed over the years to get the dentist’s situation into the hands of the correct officials who waived the $1,500 and reinstated the dentist within the network as a provider in good standing.
Dentists who volunteer on the ODA’s Dental Insurance Working Group have helped individual members with dental insurance matters they have been unable to resolve on their own for over 20 years. In the last few years alone, the working group has led successful ODA advocacy efforts to:
- Halt a major dental insurance company’s post payment audit with possible financial penalties that accompanied the audit of a Cincinnati dentist who was no longer part of the insurer’s participating provider network.
- Assist a Dayton area dentist in obtaining over $12,000 in previously denied crown claim payments.
- Assist a Cincinnati dentist in obtaining over $1,200 in previously denied crown claim payments.
- Assist a Greater Cleveland area dentist in obtaining over $4,800 in previously denied crown claim payments.
- Assist a Greater Cleveland area dentist in obtaining over $1,200 in previously denied crown claim payments.
“The ODA has an institutional credibility that can be very beneficial to individual dentists,” said Dr. Maryann Jacko, chair of Ohio Dental Association Council on Dental Care Programs and Dental Practice. “Coupling this institutional credibility with the individual personal relationships that volunteer dentists and ODA staff have developed over the years with individual policymakers and decisionmakers at many Ohio based dental insurance companies, Ohio Medicaid, General Assembly and the governor’s office can be brought to bear on different issues to assist individual practitioners with problems they can’t resolve on their own as well as bigger picture matters that benefit the profession as a whole.”
Member dentists in need of assistance simply need to contact the ODA by phone (800-282-1526 or 614-486-2700), email (dentist@oda.org) or fax (614-486-0831).
