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ADA asks Delta Dental to reject proposed disallow policy

May 09, 2016

By Kelly Soderlund

The ADA Council on Dental Benefit Programs wants Delta Dental to reject a proposed policy that would automatically disallow claims where more than two quadrants of scaling and root planing were performed on the same date of service.

Dr. Ron Riggins, council chair, sent a statement on behalf of the council to Dr. Bill Kohn, vice president of dental science and policy, on April 27 asking that the Delta Dental Plans Association policy committee reject the automatic disallow policy.

"We feel this new policy not only intercedes into dental care treatment planning but may also harm patients by creating unwarranted challenges to their scheduling for needed treatment," Dr. Riggins wrote. "Interference with the doctor-patient relationship is ever increasing and is of significant concern to the ADA."

Delta Dental will accept claims for scaling and root planing for more than two quadrants that are performed over multiple days but considers more than two quadrants on the same date of service to be a "quality of care" issue, according to the statement.

"Based on the most current published professional knowledge, it is clear that scaling and root planing for more than two quadrants on the same date of service, when performed properly, is an appropriate treatment choice," according to the council's statement. "The doctor and patient alone are in the best position to determine patient centered treatment plans and the time frames for delivery of the indicated care. A policy that automatically rejects this treatment, which is based on the doctor's best judgment, is unacceptable."

Dr. Kohn emailed a statement saying that Delta Dental Plans Association does not comment on confidential internal policy matters.

"The focus of our policies is simple: to ensure cost-effective access to quality oral health care for more than 68 million Americans," Dr. Kohn wrote. "Every year, Delta Dental, like other carriers, reviews millions of claims, watching for over-use, irregularities, and abuse. Combined with an ongoing assessment of our processing policies, this is part of our continual efforts to support evidence-based health care, best practices, avoidance of unnecessary costs for consumers, and, above all, optimal patient outcomes."

Dr. Riggins said Delta Dental's response is disappointing considering many of its state plans are already implementing this policy.

"We know for certain that member Delta companies already enforce this policy within their states based on calls to those companies and information from respective state dental associations," Dr. Riggins said. "We don't understand how this policy is cost effective. For who? The patient who has to now pay for multiple dental appointments?"

Dr. Riggins also called into question Dr. Kohn not referencing the evidence the Council on Dental Benefit Programs provided in its statement, considering it referenced a policy statement and a research study to support its definition of quality of care.

"I don't think Delta Dental executives are in a position to deem any treatment necessary or unnecessary," Dr. Riggins said. "That's at the discretion of the dentist and the patient; a relationship we want to protect and one we want to thrive."

The letter is one of many examples of the Council on Dental Benefit Programs advocating on members' behalf, Dr. Riggins said.

"We consider ourselves the champions for our members and typically have a direct pipeline to the ears of many leaders within the third-party payer industry," Dr. Riggins said. "This is why members join the ADA: to have experienced staff and volunteer leaders advocate for them so they can concentrate on their patients and practices."