ADA News

Southborough, Mass.—For nearly 40 years, Massachusetts dentists have had to abide by a regulatory order that allowed Delta Dental Plan of Massachusetts to receive an additional 5 percent discount off reimbursement fees in addition to other plan discounts.

More than a decade ago, the Massachusetts Dental Society tried to get the order lifted but was unsuccessful. But now, after a reinstated five-year battle, the New England dentists can claim victory.

"The decision supports the need for scrutiny of carrier reimbursement methods to allow fairness to both providers of care as well as those who subscribe to their plans," said Dr. Robert Faiella, ADA 1st District trustee and original chair of the task force formed to challenge Delta's fee methodology. "Insurance carriers enjoy statutory and regulatory privileges that must not allow economic injury to patients and providers through reimbursement methods."

The Massachusetts Division of Insurance found the additional 5 percent Delta Dental of Massachusetts reimbursement discount unreasonable and instructed the company to develop a new methodology. In response, Delta Dental is now developing a fee schedule that eliminates the additional 5 percent discount over three years. Delta Dental's overall discounts, including those attributable to a consumer price index that the Divison of Insurance found to be "arbitrary and therefore unreasonable," discounted fees by more than 25 percent in many cases, said Dr. Robert Boose, executive director of the MDS. The company now has to use the national dental CPI, something the MDS argued for because it thought it was a more accurate long-term look for actual costs rising year to year.

Delta Dental of Massachusetts has informed the ADA that the new reimbursement methodology will include the development of regional fee schedules. Information on exactly how those regional fee schedules will be developed and how that will affect dentists' reimbursement has not yet been made available.

"For all intents and purposes, it was a tumultuous path at best for the simple fact that it the complexity of the statutory and regulatory process was extremely challenging," said Dr. John P. Fisher, MDS president.

About 95 percent of Massachusetts dentists are providers for Delta Dental of Massachusetts, a nonprofit dental service corporation organized under state law.

The latest fight began in 2004 when the MDS House of Delegates passed a resolution directing the MDS to conduct a feasibility study about removing the discount that would be presented to the state insurance commissioner. In December 2008, the MDS received a hearing, and the Division of Insurance found unreasonable portions of the company's fee methodology applying an across-the-board 5 percent discount on fees and the insurer's use of a certain CPI to cap reimbursements for Delta's Premier participating dentists.

Relying in part on a 2006 ADA survey showing a drop in dentists' bad debt levels, the Division of Insurance held that the 5 percent discount now exceeded "a reasonable reflection of the comparative ease and certainty of payment by Delta in modern circumstances."

The discount was originally established to allow patients an easy way to pay and to make sure they did pay, a concept the MDS said is not as applicable now that dentists increasingly accept payments from patients by credit card.

Once the fee schedule is released in mid-August, the MDS will begin working with members to help them understand how it works, Dr. Boose said.

"This one, we feel, is going to be much easier to understand in terms of the day to day practice of dentistry and how people are going to be reimbursed," Dr. Boose said. "It's pretty transparent."

Delta Dental of Massachusetts' new methodology will go into effect in January 2011, according to a statement the company released. The company also announced a new voluntary program to compensate dentists for successfully managing the care of higher risk patients. Delta Dental has not yet explained how that compensation would take effect.

"Delta Dental of Massachusetts will work with dentists to track patient care, provide data to support treatment plans and help to ensure that appropriate preventative measures are in place to achieve and maintain optimal oral health," the statement said.

MDS leaders are happy the fight is over but are still working to educate members and complete the process.

"I'm elated with the success that we've had thus far," Dr. Fisher said. "But there are still obstacles that may lay before us."