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Decoding Dental Benefits: Navigating contract clauses

December 05, 2017

By David Burger

Editor’s note: This is the third in a series featuring answers and solutions for dentists when it comes to the world of dental benefits and plans. The series is intended to help untangle many of the issues that can potentially befuddle dentists and their teams so that they can focus on patient care.

Dental benefits and third-party payer issues are often rated among the most important concerns confronting dentists, and are the source of many calls to the staff of the ADA Center for Dental Benefits, Coding and Quality each day.

Decoding Dental Benefits logo And many of those calls concern the complicated legal language in clauses that proliferate in the contracts.

“Above all else, remember this: When dentists receive a third-party payer contract, they should read, understand and evaluate the contract itself — and all of the clauses — thoroughly to determine if signing it is a sound business decision,” said Dr. Dave Preble, vice president of the ADA Practice Institute. “It is also recommended that dentists check the payer’s websites to review the plan’s national processing policies as these policies can dramatically affect a dental practice.”

A comprehensive list of questions to consider when reading a contract called “What every Dentist Should Know Before Signing a Dental Provider Contract” is located online at ADA.org/dentalcontract.

Below are some common clauses within provider contracts and suggestions that dentists may use to negotiate with the payer. These clauses are described in more detail at ADA.org/dentalbenefits, the ADA’s one-stop shop on dental benefits, and part of the ADA Center for Professional Success. The ADA Contract Analysis Service for unsigned contracts is another resource. The service can provide member dentists with information concerning a proposed contract. The service analyzes:

  • Dental provider contracts with third party payers.
  • Dental management service organization contracts.
  • Contracts that offer dental school students scholarships or loans in exchange for a commitment for future employment.

For more information on that service, visit ADA.org/contractanalysis. For more information on contracts, visit ADA.org/dentalplans.

The clauses include:

  • Hold harmless: With this language, the dentist may be assuming liability for losses for which the dentist would not normally be fully responsible. “A dentist may wish to consult with his or her legal counsel and malpractice insurer about the legal and financial implications of this clause,” Dr. Preble said. “Negotiate for the carrier to provide a reciprocal hold harmless clause in favor of the dentist, which clause would require the carrier to pay the dentist for any loss that the dentist incurs due to an act or omission of the carrier.”
  • Recoupment: The ADA staff receives many calls on refund requests and usually it is the third-party carrier that is responsible for notifying the dentist of an alleged overpayment — not the other way around, even though the contract may include this stipulation. “Unfortunately some states do not have legislation that limits how far back a carrier can ask for a refund,” said Dr. Brett Kessler, chair of the Council on Dental Benefit Programs Dental Benefit Information Subcommittee. “The council has developed principles for model legislation at ADA.org/modellegislation that states can use to craft their own legislation for refund requests and other issues.”
  • Affiliated carrier: The clause allows the third-party carrier to grant to another third-party payer or administrator the right to access the rates offered under the provider agreement, even though the dentist did not sign an agreement directly with the affiliated plan. “Dentists should ask the carrier to include language in the contract that requires the carrier to notify the dentist in writing and in advance of any such third-party arrangement and allow the dentist the opportunity to opt out prior to the arrangement becoming effective,” said Dr. Kessler.
  • Most favored nations: This clause means the dentist agrees not to charge higher fees to patients covered under a particular plan than to the dentist’s other patients. “The ADA recommends that you consider asking the carrier to delete this clause from your contract,” said Dr. Christopher Bulnes, vice chair of the Council on Dental Benefit Programs. “It certainly doesn’t hurt to ask.”
  • Automatic renewal: This clause ensures that the agreement automatically renews and will never expire. “If this is a concern, a wise decision would be to ask the carrier to limit the agreement to a two-year term,” said Dr. Bulnes.
  • Compliance with policies and procedures: The ADA staff has received many calls involving the use of disallow clauses. A disallow clause means that not only will the plan not pay for the procedure but it prohibits the dentist from charging the patient for the procedure. “It is important that dentists be notified in writing and in advance of any changes to the provider manual,” said Dr. Bulnes. “The ADA has been very active in its opposition to these types of contractual clauses.”
  • Influencing members’ choice of dentists: Over the summer, the ADA sent a letter to Delta Dental Plans Association stating that various Delta Dental plans have engaged in "highly objectionable practices" in their explanation of benefits statements. The statements, the ADA claims, threaten the doctor-patient relationship by providing a list of Delta Dental network participating dentists who might charge less than the nonparticipating dentist the patient recently sought treatment from.

Staff from the Center for Dental Benefits, Coding and Quality can help dentists with their dental benefits-related problems, questions and concerns. Staff can be reached at 1-800-621-8099.

If dentists have a concern or question they would like addressed in a future issue of ADA News, they can contact dentalbenefits@ada.org.