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House approves policy opposing certain practices by third-party payers

October 31, 2016

By Kelly Soderlund

Denver — The House of Delegates adopted new policy that opposes practices by third-party payers that permit disallowed claims and other practices the Association believes are inappropriate or intrusive.

Resolution 12H-2016, Comprehensive ADA Policy Statement on Inappropriate or Intrusive Provisions and Practices by Third-Party Payers, was in response to member dentists continuing to call the ADA with concerns related to managed care agreements that interfere with the doctor-patient relationship.

"The American Dental Association opposes interference in the treatment decisions made between doctor and patient," the resolution states. "Plans which contain inappropriate and intrusive provisions substitute business decisions for treatment decisions made through a patient-doctor dialogue. Such provisions and practices deny patients their purchased benefits and robs them of their rights as informed consumers of health care."

The resolution also states that plans that contain certain provisions should disclose them to the plan purchasers and to patients and dentists should be aware of those practices when offered a contract.

According to the resolution, the ADA believes the following practices by third-party payers are inappropriate or interfere with the doctor/patient relationship:

  • Bad faith practices.
  • Inappropriate fee discounting practices.
  • Lowering patient benefits and claims payment abuse. This can include downcoding; bundling of procedures; limiting benefits for noncovered services; least expensive alternative treatment clauses; most favored nation clauses; and disallowed clauses.
  • Using non-dentist personnel for adjudication of benefit.
  • Restricting dialogue between dentists and patients or public agencies.
  • Automatic assignment of participating dentist agreements.
  • Nondisclosure of fee schedules or processing policies prior to contracting.
"We plan on sharing this comprehensive policy with the major dental carriers through the National Association of Dental Plans, Delta Dental Plans Association and Blue Cross/Blue Shield Association," said Dr. Ron Riggins, chair of the Council on Dental Benefit Programs, which proposed the resolution. "A lot of these practices aren't going to go away overnight but we want the third-party payers to know we are opposed to the practices and we want members to know we are advocating on their behalf."

For more information on contract clauses, visit ADA.org/dentalplans. The ADA Contract Analysis Service can provide dentists with information concerning a proposed contract so they can better understand and analyze its terms.

Dentists can use this service at no charge by submitting a copy of their unsigned contract and an analysis request to their state dental society.