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Your contract: Making plan decisions easier

In light of the number of calls the Council on Dental Benefit Programs receives from dentists about their dental benefit concerns, CDBP members say it's critical that dentists are familiar with the ADA Policy on Standards for Dental Benefit Plans.

"In my opinion, the dental benefit arena can be laced with pitfalls and landmines that await the unsuspecting dentist and patient," said Dr. Joseph Hagenbruch, CDBP 2008-09 chair. "Dentists should be well versed on ADA policy so they can offer guidance to patients on benefit issues when it's requested."

The ADA Policy on Standards for Dental Benefit Plans, which includes 24 provisions, reflects the Association's views on all types of dental benefit plans and serves as a useful tool for dentists, patients and plan purchasers when reviewing the many options available in the marketplace. The ADA modifies the standards as the benefit environment changes and the marketplace evolves. ADA Current Policies are available for download on ADA.org (www.ada.org/goto/policies), which includes the Guidelines on Coordination of Benefits for Group Dental Plans (Current Policies, page 91) along with other important ADA policies regarding dental benefits (i.e., coordination of benefits, page 88).

"We encourage dentists to share this information with their patients when it's appropriate so they can then share it with employer purchasers," said Dr. Hagenbruch. "The better a dentist understands the inherent challenges facing patients in terms of the vast array of dental benefit plan choices, the better the dentist can offer helpful guidance to his or her patients."

The 24 provisions include practical positions on benefit issues most important to dentists and their patients. (Visit www.ada.org/goto/top10concerns for articles about the top 10.) Among them are the predetermination process (policy numbers 14 and 15), least expensive alternative treatment clauses (policy number 17) and coordination of benefits.

For an example, noncovered services clauses, which were featured in the Sept. 15 ADA News, evoke many calls from dental offices. ADA policy on the issue—number 18—says all categories of service should be covered in a dental benefit plan and lists treatment categories, which include preventive, prosthodontics and orthodontics.

"One of my favorites," says Dr. Hagenbruch, "is item number 16, which says that the patient's agreed upon treatment plan 'shall remain the exclusive prerogative of the dentist and should not be unilaterally interfered with by third-party administrators or payers, or their consultants.'

"As for which standard appears the most frequently ignored or abused by third-party payers, I could not say for sure, but it would seem to me that lack of adherence to number 17 (Least Expensive, Professionally Acceptable Treatment), could very easily be a defining moniker for select third-party payer entities and can serve as a significant encumbrance to patients receiving quality care," Dr. Hagenbruch added.

"The part of LEAT that is often emphasized is 'least expensive,' commented Dr. James Hight, a CDBP member and chair of the Dental Benefits Information Service subcommittee. "Direct reimbursement could be a better solution. The patient, as a consumer, would have the right to choose which treatment procedure or restorative material would best meet their needs and their budget."

According to data presented at the 2008 National Dental Benefits Conference at ADA Headquarters in Chicago, traditional insurance companies are recognizing the merits of DR and have incorporated key elements in new dental benefits products.

"ADA Policy provisions can give an individual dentist or dental practice useful information and insights in deciding whether to sign a new contract or renew an existing one," said Dr. Hight. "Some dentists feel they have no choice but to participate. However, another approach may be DR. Each individually practicing dentist or dental group should determine which approach is best for them and their patients."

For more information about DR, call the ADA toll-free or at 1-312-440-2792.