ADA Policy on Standards for Dental Benefit Plans
ADA Policy on Standards for Dental Benefit Plans is as follows:
(1) Organized dentistry at all levels should be regularly consulted by third-party payers with respect to the development of dental benefit plans that best serve the interests of covered patients.
(2) Joint efforts should be made by organized dentistry and third-party payers to promote oral health with emphasis on preventive treatment.
(3) Plan purchasers should be informed that oral conditions change over time and, therefore, "maximum lifetime benefit" reimbursement restrictions should not be included in dental plans. Dental plans should be designed to meet the oral health needs of patients.
(4) Patients should have freedom of choice of dentist and all legally qualified dentists should be eligible to render care for which benefits are provided.
(5) Plans that restrict patients' choice of dentists should not be the only plans offered to subscribers. In all instances where this type of plan is offered, patients should have the annual option to choose a plan that affords unrestricted choice of dentist, with comparable benefits and equal premium dollars.
(6) The provisions and promotion of the program should be in accordance with the Principles of Ethics of the American Dental Association and the codes of ethics of the constituent and component societies involved.
(7) The design of dental benefits plans differs from that of medical plans:
- Dental disease does not heal without therapeutic intervention, so early treatment is the most efficient and least costly.
- The need for dental care is universal and ongoing, rather than episodic.
- The need for dental care is highly predictable and does not have the characteristics of an insurable risk.
- The dental needs of individuals in an insured group vary considerably.
- Patient cooperation and post-treatment maintenance is critical to the success of dental treatment and the prevention of subsequent disease.
Therefore, the American Dental Association recommends that for preventive, diagnostic and emergency services, dental benefit plans should not contain deductibles or patient copayments, because they discourage patients from entering the system. Patient participation in the cost of complex care should be sufficient to motivate patients to adequately maintain their oral health.
(8) In order that the patient and dentist may be aware of the benefits provided by a dental benefit plan, the extent of any benefits available under the plan should be clearly defined, limitations or exclusions described, and the application of deductibles, copayments and coinsurance factors explained to the patients by the third-party payers and employers. This should be communicated in advance of treatment.
The patient should also be reminded that he or she is fundamentally responsible to the dentist for the total payment of services received. In those instances where the plan makes partial payment directly to the dentist, the remaining portion for which the patient is responsible should be prominently noted in the Explanation of Benefits Statement (EOB) provided to the patient.
(9) Each dentist should have the right to determine whether to accept payment directly from a third-party payer.
(10) Third-party payers should make use of dental society peer review mechanisms as the preferred method for the resolution of differences regarding the provision of professional services. Effective peer review of fee disputes, quality, and appropriateness of treatment should be made available by the dental profession.
(11) Procedures for claims processing should be efficient and reimbursement should be prompt. The third-party payer should use or accept the American Dental Association's "Attending Dentist's Statement" (claim form) and the Code of Dental Procedures and Nomenclature that the Council on Dental Benefit Programs has approved after appropriate consultation with representatives of nationally recognized dental benefit organizations and the ADA-recognized dental specialty organizations.
(12) Dentists should comply with reasonable requests from third-party payers for information regarding services provided to patients covered under a plan.
(13) Third-party payers' administrative procedures should be designed to enhance the dentist-patient relationship and avoid any interference with it.
(14) When patient eligibility is certified through the predetermination process, the third-party payer shall be committed to reimburse on the basis of that initial certification within the provisions of that plan, unless and until written notification is provided in a timely manner to the dentist and the patient by the payer that change in eligibility status has occurred.
(15) When such a change in eligibility occurs, a period of not less than 30 days should be allowed for continuation and, when possible, completion of treatment.
(16) The treatment plan of the attending dentist, as agreed upon by the patient, shall remain the exclusive prerogative of the dentist and should not be unilaterally interfered with by third-party administrators or payers, or their consultants.
(17) The American Dental Association opposes any abuse of the "Least Expensive, Professionally Acceptable Treatment" concept and will inform the public of the barrier such abuse represents to the attainment of quality dental care. When an insoluble dispute occurs between an attending dentist and third party regarding a treatment plan, peer review should be accepted by all parties involved as the mechanism for solution. Peer review should be entered into prior to the third-party payer's determination of reimbursable benefits in such cases.
(18) A dental benefit plan should include the following procedures:
A. Diagnostic. Provides the necessary procedures to assist the dentist in evaluating the conditions existing and the dental care required.
B. Preventive. Provides the necessary procedures or techniques to assist in the prevention of dental abnormalities or disease.
C. Emergency Care. Provides the necessary procedures for treatment of pain and/or injury. It should also cover the necessary emergency procedures for treatment to the teeth and supporting structures.
D. Restorative. Provides the necessary procedures to restore the teeth.
E. Oral and Maxillofacial Surgery. Provides the necessary procedures for extractions and other oral surgery including preoperative and postoperative care.
F. Endodontics. Provides the necessary procedures for pulpal and root canal therapy.
G. Periodontics. Provides the necessary procedures for treatment of the tissue supporting the teeth.
H. Prosthodontics. Provides the necessary procedures associated with the construction, replacement, or repair of fixed prostheses, removable partial dentures, complete dentures and maxillofacial prostheses.
I. Orthodontics. Provides the necessary treatment for the supervision, guidance and correction of developing and mature dentofacial structures.
(19) The financial reserves of the plan should be adequate to assure continuity of the program.
(20) Reimbursement schedules and claim documentation requirements should be based on procedures performed by the dentist and not on the specialty status of the dentist performing them.
(21) The methodology used by plan administrators to set reimbursement schedules or percentiles, or for UCR and/or MAB determinations should rely on current, geographic and other relevant data and be readily available to patients, plan purchasers and dentists.
(22) Profiling to establish a different rate of reimbursement for the provider should not be used as a means of cost control by the plan administrators.
(23) The data, calculations and methodology used for practice profiling of individual dentists should be made available to those dentists upon request.
(24) Information on the possibility of post-payment utilization review, and any consequences of same, must be provided to both participating and non-participating dentists.