Member Support on Third-Party Issues
The ADA strongly opposes interference by third-party payers in the dentist-patient relationship. Any medical necessity determination by third-party payers should be limited to adjudication of the dental benefit. Some examples of payer practices that the ADA is opposed to include:
- Failure to properly investigate the information in a submitted claim
- Unreasonably and purposely delaying or withholding payment of a claim
- Withholding funds from bulk benefit payments for services rendered to unrelated patients as a means of settling disputes over prior claims experience with the dentist either from an alleged past overpayment by the plan or retroactive ineligibility of benefits for a patient.
- Issuing reimbursement checks which, upon signing, result in the dentist accepting the amount as payment in full
- Using claim forms which, upon signing, require the dentist to accept the terms of the plan’s contract
- Issuing documentation that states the submittal of a claim by a dentist means that he or she accepts all terms and conditions set forth in the participating provider contract
- Sending communications to patients of nonparticipating dentists which state the patient is not responsible for any amount above the maximum plan benefit.
- Using language within the Explanation of Benefits statements that interferes with the doctor-patient relationship
- Lowering patient benefits either by downcoding, bundling of procedures, or using least expensive alternative treatment clauses when adjudicating claims for completed services
Further, the ADA strongly opposes the practice by carriers of “disallowing” claims for a covered service that was agreed upon and completed by the treating dentist.
Recent Advocacy to Payers
Statement Sent to Delta Dental Regarding Scaling and Planing 04/2016 (PDF)
Letter to Delta Dental on Disallow Policy 06_2016 (PDF)
To receive support and report to the ADA what you believe are abusive practices by third-party payers, please contact:
ADA Member Service Center
Or you can use the ADA online complaint form: Third-Party Complaint Form