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Assignment of benefits legislation example of ADA's advocacy efforts

July 27, 2018

By David Burger

Editor's note: This is the 16th story in the Decoding Dental Benefits 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.

Dentists are dentists because they want to be dentists.

They don't want to be in the debt collection business.

Yet that often happens because some patients will not or cannot pay them, even after receiving reimbursement from a third-party payer. A simple solution might come to mind — third-party payers should just pay dentists directly. Problem solved.

DDB LogoHowever, some third-party payers only pay directly or "assign benefits" to dentists participating in their networks.  Non-participating dentists must then seek payment from the patient, even when the patient indicates on a signed claim form that the dentist should be paid directly. That is, unless there's a law.

That is why assignment of benefits legislation is active in many states, with about half having passed laws that, in varying degrees, require third-party payers to follow the patient's directive to pay the dentist directly for covered services. Each state's approach varies slightly, but the end result is a law that allows patients to choose how the dental coverage they've purchased is utilized.

The ADA Department of State Government Affairs works closely with state dental associations to develop and help pass laws that would prohibit insurers from denying the patient's request that reimbursement for covered services goes directly to the dentist. Paying the patient instead of the dentist is thought to be a method used by carriers to encourage the dentist into joining the network, said Dr. Cynthia Olenwine, a retired Pennsylvania dentist who is a member of the ADA Council on Dental Benefit Programs has been working closely with the Department of State Government Affairs in trying to pass legislation in her state. With active advocacy by the Pennsylvania Dental Association, the bill is moving forward, and if all goes as planned, it will be voted on in September, Dr. Olenwine said..  

photo of Dr. Olenwine
Dr. Olenwine
The law is important to her and other Pennsylvania dentists, she said, for a simple reason: Without the law, the marketplace may "force patients to go to a dentist they don't want to go to and forces them to potentially pay upfront to see the dentist of their choice."

Not allowing patients to assign benefits has two negative effects on consumers, Dr. Olenwine said. For one, access to care may be a challenge for patients since they may have to pay at the time of dental service (which may be unaffordable) and await reimbursement from their insurer; and two, the dentist will have to contact patients for payment after services have been rendered, which is often confusing to patients who expect their insurers to pay dentists directly.

Dr. Olenwine said that rural patients in Pennsylvania, in particular, are placed at a disadvantage because there are some counties where only one or two in-network dentists provide care. Patients who cannot afford to pay upfront may postpone needed care, and they also incur greater travel costs to seek treatment from an in-network dental provider.

Dr. Olenwine pointed out another aspect of what could happen in the case of divorced or separated parents, where one parent has primary custody of a child who is insured through the other parent. The custodial parent may never see the insurer's reimbursement check, which is sent directly to the other parent. Or, in another instance, a custodial parent often encounters financial burdens, preventing them from seeking dental care for children. Children are either not receiving care or their parent must switch to a participating in-network dentist who is not necessarily the parent's first choice.

To help dentists join the effort to pass assignment of benefits laws, the ADA has provided model legislation to state dental associations. Based on decades of state advocacy experience, the Department of State Government Affairs provides research and examples of dental benefit advocacy approaches for members and societies to use in helping patients gain access to the benefits for which they have paid. The department has developed a toolkit series for state societies that explores, where available, the most current legislative trends with simple, easy-to-follow overviews, recommended strategies, descriptions of benefits, available research and opposition messaging. The toolkit is available upon request.

To contact State Government Affairs, email oconnor@ada.org or call 1-312-440-2525. Follow ADA advocacy at ADA.org/advocacy.

The ADA has also created an online landing page for dental benefits information that can help dentists address and resolve even their most vexing questions. Go to ADA.org/dentalbenefits, part of the ADA Center for Professional Success.

Staff from the Center for Dental Benefits, Coding and Quality can help dentists with dental benefits-related and coding problems, questions and concerns. Call the ADA's Third Party Payer Concierge at 1-800-621-8099 or email dentalbenefits@ada.org.

Previous installments in the Decoding Dental Benefits series are available at ADA.org/decoding.