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Contract Analysis Service helps dentists decipher affiliated carrier clauses

February 06, 2012

By Kelly Soderlund, ADA News Staff

Dr. Richeson

When it comes to signing a third-party payer’s participating provider agreement, it’s always good to read and understand the fine print.

Especially when it comes to an affiliated carrier’s clause, which makes the dentist a participating provider for the affiliated carrier, even if the dentist never signed a contract with said carrier. ADA staff members have been fielding numerous calls from dentists asking how they became a participating provider for a third-party carrier without signing a contract with that particular carrier.

It happened to Dr. Larry Miller.

Dr. Miller, who practices in Twinsburg, Ohio, said his office contracts with several insurance plans. His receptionists started noticing reduced reimbursements for patients with coverage by a plan she didn't recognize.

“We didn’t have a contract with the insurance carrier but they were doing our explanation of benefits as if we did,” Dr. Miller said.

It turns out, one of the contracted carriers had apparently sold or leased its plan with the fee schedules to another carrier, he said. Dr. Miller called to complain and the affiliated carrier sent him a form to fill out, allowing him to opt out.

It was an easy solution, but the situation left Dr. Miller confused as to how it could happen in the first place.

“Looking at the contract, you would not know they had the ability to do that,” Dr. Miller said. “But obviously, to have an outside party review the contract is not a bad idea.”

The ADA Council on Dental Benefit Programs wants to remind dentists to carefully review contract clauses and provisions before signing participating provider agreements, said chair Dr. Jim Richeson. This includes reviewing the plan's website, participating provider manuals and other materials.

Some states have passed regulatory requirements that force carriers to disclose partnerships or network arrangements and many carriers include these clauses in their participating provider agreements, Dr. Richeson said.

“According to the dental benefits industry, these clauses are necessary to keep pace in a competitive marketplace,” Dr. Richeson said. “It is not unusual for a carrier to have multiple subsidiaries, as some states require that carriers operate under a separate company in their respective states. Since these types of details may not be known when contracts are initially signed, these types of clauses are included in participating provider agreements.”

Dr. Richeson and CDBP also encourage dentists to be educated about provider contracting considerations, which can impact their practices.

“You have the right to negotiate the terms of a participating provider agreement; however, the plan also has contractual rights that may affect your rights,” Dr. Richeson said. “It certainly doesn’t hurt to ask if you have concerns with specific clauses in the participating provider agreement.”

The ADA offers its Contract Analysis Service for this very purpose. Individual dentists have access to the service, which provides a clear, plain language explanation of contract terms and is designed to allow dentists to make informed and independent decisions on the merits of participating dentist contracts. The service is free to members who request a review through their constituent dental society and costs $50 for members who contact the ADA directly.

To learn more about the Contract Analysis Service, visit Contract Analysis Service.