ODA going to bat for dentists when it comes to dental insurance

Ohio Dental Association membership surveys have consistently reported that ODA members rank the “monitoring [of] the dental insurance industry and advocating dental insurance benefits” as a high priority objective for the association. The dentists who volunteer their time at the American Dental Association, ODA and local dental societies and the professional staff at each level of the tripartite take the membership’s sentiments seriously and have focused significant resources to advocating on behalf of individual dentists and the profession as a whole on dental insurance matters.

The ODA and ADA have both set up a process to assist individual member dentists when dealing with problem dental insurance issues.

The ODA Dental Insurance Working Group meets on the second Tuesday of every month and determines the ODA’s role in addressing dental insurance related questions, concerns and complaints involving third-party payers that are submitted by ODA member dentists. It is comprised of volunteer general dentists and specialists who also serve on the Council on Dental Care Programs and Dental Practice. Current working group members include:  Drs. Jackie Cerar (Mentor), Joe DePalma (Dillonvale), Mary Hanlon (Cincinnati), Purnima Kumar (Columbus), Manny Chopra (Cincinnati), Greg Michaels (Lancaster), Rick Ragozine (Girard), Jason Streem (Cleveland) and Dave Vorherr (Cincinnati).

The working group’s efforts over the years have demonstrated the value of membership to the individual dentists who contacted the ODA for assistance while also generating information that the rest of the membership can utilize in their own practices. They also represent cases where the individual dentists were ineffective in addressing their concerns to dental insurance companies and needed the strength of the larger organization to obtain some form of relief for their concerns.

Issues the working group has helped individual members address have ranged from denials or limitations for certain services (such as core buildups, crowns, endodontic therapy, scaling and root planning and radiographs); payment of non-contracting dentists; applications of participating provider agreements; application of least expensive alternative benefit clauses; participating provider listings; focused review, utilization review and other types of audits; overpayment recovery; and CDT dental code usage. Irrespective of the ultimate outcome of the case, the dentist was provided documentation of the ODA’s efforts that they could use to add credibility to their position with their patients.

The ODA has been successful in assisting wide groups of member dentists on larger scale issues too.

The ODA’s advocacy and use of regulatory directives with numerous insurance companies and third party administrators (TPAs) has resulted in dentists having the option of how they wish to receive reimbursement, i.e. via virtual credit cards with much higher than usual transaction fees, electronic funds transfer (EFT) or paper check.

The ODA and Delta Dental of Michigan, Ohio, and Indiana have worked together to publicize a clearer understanding of what dentists need to do in order to be reimbursed for providing a full mouth scaling and root planing service during one appointment. That is, to not have the claim automatically disallowed, the dentist needs to provide supporting documentation that the procedure was done during a single visit because 1) the patient was sedated or 2) medically compromised or 3) the dental office location required the patient to travel some distance to get there or 4) the patient requested the service for their own purposes.

It is also important to realize that Delta Dental expects the dentist to devote an appropriate amount of time to providing the service while also having appropriate documentation on hand to back up the claim.

This joint effort has resulted in another project that has the potential to be, as far as we know, a first in the nation. The ODA and Delta Dental are working on the idea of having a party independent of Delta Dental to provide a final means of appeal for ODA member dentists who have dental insurance disputes with Delta Dental on cases involving medical necessity and quality of care issues. As it is currently envisioned, an ODA member dentist who has a relevant claim disallowed would first utilize Delta Dental’s internal appeals process. If the dentist is still dissatisfied with the results of the internal appeals then he/she would be able to appeal Delta Dental’s decision to the ODA where a proper mix of appropriately trained general dentists and/or specialists would be appointed by the ODA Council on Dental Care Programs and Dental Practice to review the case and issue a final determination.  Once implemented this free of charge program will only be available to ODA member dentists.

Another larger scale project that will benefit thousands of Ohio dentists involves legislative advocacy efforts to enact non-covered services legislation.

Senate Bill 148, introduced by State Sen. Kirk Schuring and co-sponsored by State Sens. John Eklund, Matt Huffman, Lou Terhar and Joe Uecker, would prohibit insurance companies from dictating the fees that contracting dentists may charge for services that are not covered by the patient’s dental benefits plan.

It seeks to undo unfair contract provisions that can unnecessarily interfere with a patient’s relationship with their dentist. In some cases, the imposed reimbursement level is too low to meet the dentist’s actual costs of providing care, leaving the practitioner unable to perform the procedure. Even if the patient wishes to remain with the practice and offers to pay the dentist’s usual and reasonable fee, accepting that offer could put the dentist in breach of their participating provider agreement. This forces the patient to either seek treatment from another dentist who is not under contract or forgo the procedure altogether.

Passage of this initiative has been and continues to be a legislative priority for the ODA’s legislative advocacy team and the grassroots member dentists who are working to enact it in the face of powerful opposition that includes major insurance companies, labor unions and business organizations.

“The ODA has been and will continue to be an active advocate for ODA member dentists when it comes to dental insurance issues,” said Dr. Manny Chopra, chairman of the ODA Council on Dental Care Programs and Dental Practice. “I encourage all members to take a role in advocating for the profession with such issues as enacting non-covered services legislation while also utilizing the assistance that the ODA and the American Dental Association can and do provide to individual members who encounter difficulties with dental insurers.”