Third-Party Payer Advocacy
Dental benefits and third-party payer issues are often rated among the most important concerns confronting dentists. It is important to understand that when it comes to interactions with third party payers, federal antitrust laws may limit the scope of what the ADA can do in terms of third party payer reimbursements and accompanying benefit policies. Learn more about Antitrust laws.
The resources below can help every dentist navigate the third party payer environment, whether you are trying to make a decision on signing the contract (by far the most important decision for your practice), you are already participating in a plan, or you have chosen to remain out of network. In addition to providing resources to help you succeed, ADA’s advocacy efforts along with its state partners, has helped implement legislation to aide in establishing an environment where dental practices can succeed. Learn more about ADA’s Legislative Advocacy effort.
Resources (click on the accordion file for more information)
Making a Decision to Sign A Contract
This is one of most important decisions any dentist will make. Should you participate in any plan? Which payers should you participate with?
There are at least three main issues to consider when making this decision:
Contracts Clauses – The negotiation between dentist and carrier is not a negotiation between equal partners. Payers often send template contracts to dentists for signature. Learn more about contract issues so you can use this knowledge to better negotiate with payers before you sign the contract.
Contract Issues (ADA Member Login Required)
Fees and Discounts – ADA has limited ability to influence reimbursement rates, and dentists cannot jointly negotiate. The ADA Survey of Dental Fees is a great tool to benchmark your practice fees and individually determine your appropriate fee schedule.
Participating in a Plan
After fully reading and understanding the contracts and your practice dynamics, you may decide to participate in a payer’s network. Once you sign, successfully navigating the third-party payer world requires a strong office team with an office manager who understands coding and dental benefits issues.
Always remember that even though you have agreed to participate in the payer’s network and offer discounts to plan enrollees, the benefit ultimately belongs to the patient. Concerns regarding benefit reductions to the patient are best addressed through the plan’s purchaser (the patient or the patient’s employer). Here are some resources to help you navigate this field.
Office financial policy – Patients may believe that all recommended treatment should be a covered benefit, but it’s important to point out that dental benefits are not intended to pay for all care. Proactively establishing an office financial policy is a “must-do” to support a successful practice. Visit
Managing Patients | Policies: Financial: Payment Options, Insurance Handling and check out the sample financial policy statement.
Coordination of benefits and managing write-offs – Some patients may have multiple plans and it is an onerous task to make sense of what needs to be collected and from whom. Check out the
ADA’s Guide to Coordination of Benefits.
Explanation of benefits (EOB) and denial language – Consider sending your payer representative information on the ADA’s model
Explanation of Benefits. If you encounter language on an EOB you feel is important or unwarranted, contact us at
Getting Paid: CDT Code – The ADA supports maintenance of the CDT Code through a transparent, multi-stakeholder process. It’s important to note that just because there is a code for a recommended treatment, it does not guarantee the procedure is covered under the patient’s plan. However, knowing how to code appropriately for the services rendered can help ensure timely payment and may limit audit requests from a payer. Review some frequently asked questions about the CDT Code, the CDT Companion and the claim form completion instructions. Remember: always report your full fee on the claim form!
Communicating to carriers and employers – Visit our section of
Sample letters you can use to send to third-party carriers and employers regarding dental services that the plan does not consider necessary.
Appealing a denial – Do you need to appeal a denial? Review the
Tips for a Successful Appeal
Maintaining good patient records– Regardless of whether you participate with a dental plan, it is always important to maintain accurate and complete dental records. The claims for treatment submitted to a payer should match the information in the patient’s record. All claims should be signed and dated. For more information on keeping good records, check out Managing Patients | Treatment Recommendations Documentation/Patient Records and Managing Finances | Risk Management and Fraud Prevention.
Patient education – Patients may think of dental benefits in the same way they do medical insurance. Medical care can be very expensive and insurance is necessary for most patients to afford even routine care. However, routine preventive dental care is not as expensive and insurance is not required. Instead, patients receive a benefit that helps them pay for the care they need. Help your patients understand what dental “insurance” means through the
Why doesn’t my insurance pay for this? brochure, and feel free to provide them with the ADA’s free patient resource: Your Guide to Finding and Paying for Dental Care.
An unwanted contract? – At some point you may wish to re-negotiate a contract. Use
Strategies for an Unwanted Contract from the ADA to help you with this situation. Contracts can be terminated. Your contract will usually stipulate a specific process to terminate a relationship with the payer you are contracted with. The carrier may require a specific notice period along with other requirements. Be sure to read and comply with all requirements when terminating your contracted participating status.
More questions? Try our
frequently asked questions on dental benefits and our Third Party Issues Checker.
Not Participating in a Plan