DENTAL INSURANCE WORKING GROUP AND MEDICAID WORKING GROUP CONTINUE ASSISTING MEMBER DENTISTS WITH PROBLEM CLAIMS AND OTHER MATTERS – PART 2
Last month, this column focused on the ODA’s efforts through the Medicaid Working Group to help individual ODA member dentists address Medicaid related problems that they are unable to resolve on their own. This month’s column will cover how the ODA helps individual member dentists deal with privately funded dental insurance related issues.
Privately funded dental insurance
The ODA Council on Dental Care Programs and Dental Practice (CDCPDP) created the Dental Insurance Working Group (DIWG) in 2003 to assist ODA member dentists on an individual basis address dental insurance questions, concerns, complaints, problems, etc. that the member is unable to resolve on their own. Dentists who currently volunteer their service on the DIWG have over 200 years of collective experience in private practice. In the 22 years since the working group has been in existence, an average of around 20 ODA members have utilized its services each year to address dental insurance matters they were unable to resolve on their own.
Helping individual dentists
The ODA has in recent years, through the working group and/or council:
- Assisted many member dentists obtain reimbursement for dental insurance claims that had been held up for various reasons, including unpaid claims that resulted from the Change Healthcare ransomware attack and data breach, redundant information requests and failure of a benefit plan sponsor (employer) to provide reimbursement funding for the insurance company to pay the dentist’s claim.
- Intervened to successfully halt MetLife’s post payment audit of a member dentist who was no longer part of the insurer’s participating provider network.
- Provided member dentists with public relations “cover” in cases where the dentist’s treatment was appropriate but limitations in the patient’s benefit plan caused their insurance claim to be denied.
- Assisted individual member dentists and their offices work through issues related to audits and focused review, billing when the treating dentist was different from the billing entity, bundling, claim denials, appeals and resubmissions, coding, credentialling and network enrollment/termination, filing complaints with insurance regulators, insurance company clinical and documentary criteria, Ohio’s non-covered services law, overpayment recovery and the proper use of the periodontal scaling and root planing (D4341 and D4342) and full mouth debridement (D4355) procedure codes.
Addressing issues on a large scale
ODA representatives have met in recent years with representatives of major insurers and third-party payers including Avesis, CareSource, Cigna Healthcare, Dental Care Plus Group, DentaQuest, Centene Dental Services (formerly known as Envolve Dental), LIBERTY Dental Plan, Medical Mutual, Ohio Bureau of Workers’ Compensation, Ohio Department of Medicaid, Superior Dental Care and Sun Life on a variety of issues. The CDCPDP is currently scheduled to meet with Anthem Blue Cross Blue Shield and LIBERTY during its July meeting. ODA representatives have also served, or will be serving, on Delta Dental of Michigan, Ohio, and Indiana’s Dental Professional Advisory Workgroup and DentaQuest’s Dental Advisory Committee.
All of these interactions have helped the dentists who volunteer at the ODA and the ODA staff to develop personal and professional relationships with many of the dental insurance companies that do business in Ohio.
Large numbers of Ohio dentists have collectively received help from the ODA’s dental insurance advocacy efforts in recent years. For example, many dentists were adversely impacted when the Dental Care Plus Group (DCPG) made changes to its crown claim payment criteria after being bought by DentaQuest and then Sun Life. These changes resulted in a marked increase in crown and core buildup claim denials. Many did not believe the new criteria was appropriate or justified. The ODA and grassroots dentists expressed their concerns to DCPG/Sun Life and the insurer responded favorably to the profession’s concerns. Modifications were made which resulted in the enactment of more practical and user-friendly crown and core buildup claim payment criteria.
DCPG was created over 30 years ago as a dentist owned dental insurance company. Its creation included a 20% withhold on dental claim payments to dentists in order to bolster the company’s financial stability. Many network dentists questioned the continued necessity of the withhold as DCPG grew and particularly after DCPG was acquired by DentaQuest. When Sun Life then bought DCPG/DentaQuest, the ODA met with Sun Life about a number of issues, including the withhold. Within months after hearing the ODA’s concerns, Sun Life put in place a plan to eliminate the withhold in its entirety. That plan has been faithfully executed and the withhold has been removed.
Dental fees
The ODA has built an ongoing relationship with the Ohio Bureau of Workers’ Compensation over the years. This relationship has resulted in Workers’ Comp contacting the ODA on an annual basis for direct input into its development of the BWC dental fee schedule.
The ODA formally objected to decisions by Aetna and Cigna to lower their reimbursement rates for network dentists while also advocating for higher fees from Aetna, Cigna and Delta Dental of Michigan, Ohio, and Indiana. The ODA’s efforts with Delta Dental did help lead to an increase in its payment levels by modest amounts to its network dentists at the same time other insurance companies were lowering their reimbursement rates.
Crown claim submission requirements
ODA representatives met with representatives of LIBERTY Dental concerning LIBERTY’s requirement plan criteria and medical necessity guidelines for crowns that required “post-operative radiograph(s) showing the delivery of the crown must be included with claim submission for payment.” As a result of the meeting, LIBERTY agreed to discontinue the requirement if a dentist deems it not appropriate to take a post treatment radiograph and will instead accept an alternative proof of liability like a photograph.
Legislative advocacy
One of the most recent ODA legislative victories involves the passage of Senate Bill 40, the non-covered services bill. The new law, which took effect at the beginning of the year, bars insurance companies from contractually requiring dentists to accept their fee schedules for services not covered by the insurer. Contracting dentists are free to charge their usual fee for services that meet the definition of a non-covered service.
The CDCPDP met with high-level representatives of Delta Dental last year when the non-covered services law was adopted by the state legislature concerning the insurer’s implementation of the new statute. The council came away from this meeting expecting that there would be no problems with the roll out of the new law. This positive belief has held true as Delta Dental and the other major insurers operating in Ohio have implemented the law in a very dentist friendly manner.
Other ODA dental insurance advocacy successes over the years have included the adoption of Ohio laws or regulatory guidance that:
- Provides dentists who want to set up their own in-office dental plan or membership plan with clear guidance on how to do so in a legally acceptable manner.
- Prohibits the creation of silent PPOs.
- Creates a regulatory framework for how leased networks must operate.
- Designates the standardized credentialing form that insurance companies must use.
- Designates the ADA claim form as the standardized form for submitting dental insurance claims.
- Creates a 30-day prompt pay law for electronically submitted claims.
- Establishes limitations and requirements on insurance companies that seek to recover overpayments.
- Addresses insurance company and third-party payer use of virtual credit and debit card payments.
Contract Analysis Service
Organized dentistry 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.
In-office Dental Plans or Membership Plans
In-office dental plans or membership plans provide alternatives to traditional dental insurance and third-party discount plans. They allow dentists to offer patients the ability to join the plan and pay a monthly or yearly fee directly to the dental practice in exchange for services and discounts created by the dentist.
The ODA Services Corp. (ODASC) endorses DentalHQ, a platform that helps dentists create, customize and automate their in-office membership plans. With the DentalHQ platform a dentist has total control over setting the fees and enrolling patients and allows for easier member management and payment options.
Plans for All (PFA) gives ODA member dentists’ practices the ability to offer customized plans not just for uninsured patients, but for insured patients as well. It helps fill the gaps insurance leaves behind, making treatments like whitening, fluoride, and even Botox more accessible while driving patient loyalty and boosting practice revenue. DentalHQ has reported its membership plan platform helps dentists boost patient retention by 90% and treatment acceptance by 25%.
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 https://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.
Utilizing ODA Member’s Only Resources
ODA staff can be reached by phone (800-282-1526), fax (614-486-0381) or email (dentist@oda.org) to answer questions, provide direction, resources and assistance. With nearly 95 years of combined experience, the ODA staff have the experience, institutional knowledge, legal expertise and oftentimes personal and professional contacts to assist members and/or their offices to successfully address confounding dental insurance problems, issues and questions.
If an issue is beyond the ODA staff’s ability to address or requires a more formal response, then member dentists can utilize the services of the DIWG. The DIWG meets on the second Tuesday of each month while the Medicaid Working Group meets on an as needed basis.
ODA members who would like to utilize the working group’s services should submit their question, concern or request for assistance along with supporting documentation that does not include patient identifiers (e.g., a description of the situation along with all of the information the dental office submitted to and received from the insurance company including claims, photographs, radiographs, charting, appeal, explanation of benefits, etc.) to the ODA (www.oda.org; 1370 Dublin Road, Columbus, Ohio 43215; 614-486-0381 FAX; or dentist@oda.org). All patient identifiers must be redacted from the information that is submitted to the ODA to avoid HIPAA complications.
The Dental Insurance Working Group’s services are free of charge but only available to ODA member dentists.
