Misleading explanation of benefits statements highlight need for standardization
March 09, 2018
Editor's note: This is the ninth 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.
Dental offices have lodged complaints to the ADA about explanation of benefit statements that are incorrect or need to be clarified, but the Association has resources available for dentists when dealing with third-party payers.
The ADA has taken a strong position in advocating for clear EOBs, said Dr. Brett H. Kessler, a member of the ADA Council on Dental Benefit Programs.
"The language should provide information that clearly delineates the benefit limitations of the plan and any balance due to the dentist by the patient," he said. "Importantly, it should not wrongfully interfere with the dentist-patient relationship."
In at least one state, a legislator has decided to address problematic EOBs.
Dr. Michelle Caldier is a dentist and state representative in the Washington state legislature, and is tackling the issue of what she sees as improper EOBs from third-party payers.
"After joining the legislature in 2015, I received numerous complaints about misleading EOBs from Delta Dental, in which the company was denying payment to providers for services they should have paid and reporting the amount they denied as an 'in-network benefit,'" Dr. Caldier said. "Last year, I introduced House Bill 1316, which would have established fair dental insurance practices and required the Office of Insurance Commissioner to convene a work group to study EOBs. Although the bill didn't pass, the [commissioner] ended up convening a work group anyway, and discovered numerous misrepresentations to patients. The [commissioner] then established recommendations, which were wrapped into another bill I introduced this year, House Bill 2502. Unfortunately, the majority party did not advance that bill forward either."
Despite the setbacks, Dr. Caldier said she would re-introduce the bill at the next legislative session, an action the Washington State Dental Association — included in the work group — supports.
The state's insurance commissioner identified a number of concerns with dental EOBs, according to Dr. Cynthia Pauley, president of the Washington State Dental Association:
- Dental EOBs are not required to follow a standard format or standard definitions of terms.
- Information on EOBs can be confusing and can lead to misunderstanding.
- Some did not follow minimum requirements for the parties to do business in their name or follow other minimum disclosure standards.
- Some include misrepresentations about what the carrier paid, what the provider received and how the member's cost share had been determined.
Dr. Caldier's experience underlines the fact that the language in EOBs can create confusion between patients and dentists.
In an effort to get insurance companies and dental offices on the same page, the ADA has drafted a position on EOBs, available at Success.ADA.org. In it, the ADA urges dental benefit carriers to consider these principles, statements and recommendations as part of the EOB statements they submit to dental beneficiaries and dental offices.
"Clear and accurate communication between patients, dentists and dental benefit payers is essential to the delivery of oral health care," said Dr. Kessler. "EOB statements written in this fashion can help to strengthen and support that message."
The ADA has created a landing page for dental benefits information that can help dentists address and resolve even their most vexing questions, ADA.org/dentalbenefits, part of the Center for Professional Success.
Previous installments in the Decoding Dental Benefits series are available at ADA.org/decoding.
Staff from the Center for Dental Benefits, Coding and Quality can help dentists with dental benefits-related problems, questions and concerns. Call 1-800-621-8099 or email email@example.com for questions.
If dentists have a concern or question they would like addressed in a future issue of the ADA News, they can contact firstname.lastname@example.org.