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Survey: Third-party payer issues can cause midnight headaches

November 29, 2018

By David Burger

Editor's note: This is the 21st 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.

What keeps dentists up at night?

Photo of Dr. Kessler
Dr. Kessler
The ADA Council on Dental Benefit Programs conducted a 2018 survey with state dental societies to confirm what it already suspected: that third-party payer issues keep member dentists tossing and turning and too often consumes their time when they would rather be treating patients.

The above question was one of the survey questions, and here are some of the anonymous answers:

  • "Arbitrary and capricious policy and reimbursement changes by insurance companies."
  • "How do I keep my practice growing and thriving while providing the highest quality care to my patients in an environment of competition and pressure from insurance companies?"

What interested members of the council was the impression that the ADA wasn't doing enough. More answers:

  • "Insurance companies manipulating the practice of dentistry and the ADA not being able to counteract this trend."
  • "Inability of ADA to fight against insurance companies and government regulations."
  • "The ADA allows insurance companies far too much control over our industry."

Dr. Brett Kessler, a Colorado dentist and vice chair of the Council of Benefit Programs, has read the data and said he understands member dentists' perception that the ADA hasn't advocated for change and can't help them with their problems. He represents the 14th district, comprising seven states — Wyoming, Nevada, Utah, Colorado, Arizona, Hawaii and New Mexico — and often travels to state society meetings and caucuses to report on what the council is doing.

DDB Logo"What impresses me personally is all of the increasing measures the ADA has done to address members' concerns regarding dental benefits," Dr. Kessler said. "I've heard loud and clear what troubles my colleagues, and my message is that the ADA is taking several measures to help."

One of Dr. Kessler's favorite ADA resources is the newly launched Third-Party Payer Concierge, an exclusive member perk that connects dentists with ADA staff from the Center for Dental Benefits, Coding and Quality to help resolve dental benefit issues and answer coding questions.

Recently, the ADA staff has helped members with third-party payer issues in:

  • Providing guidance in the appeals process when a claim has been denied.
  • Contacting dental plans to revise explanation of benefits language that could potentially damage the dentist-patient relationship.
  • Connecting individual dentists with a dental plan's consulting dentist.
  • Clarifying requirements on electronic fund transfer payments.

"When people call me with questions I can't answer, I send them right to the Concierge," Dr. Kessler said. The Concierge has fielded more than 7,000 calls this year guiding members through their issues." 

Another resource that Dr. Kessler said has been invaluable to him is the ADA's new online landing page for dental benefits information that can help dentists address and resolve even their most vexing questions: ADA.org/dentalbenefits, part of the ADA Center for Professional Success.

"Most dentists are frustrated with the challenges surrounding dental benefits — reducing reimbursements, staff time on hold researching patient's benefits, denial or disallowing of procedures, patients' frustrations as they realize that their plan doesn't cover everything they thought it would; the list goes on and on," Dr. Kessler said. "The ADA website has a variety of articles, webinars, videos, checklists and other resources to help dentists navigate their way through the various dental plans and their restrictions, exclusions, alternate benefits and other limitations, as well as addressing any other worry."

In an effort to assist dental practices overcome the increasing administrative burden that comes with participating in dental benefit plans, the ADA has taken two major steps, Dr. Kessler said. The first was the establishment of the ADA credentialing service, powered by CAQH ProView. The second was the August convening of the first-of-its-kind Administrative Efficiencies Summit which brought together ADA member dentists, payers, clearinghouses, practice administrators, software vendors and other stakeholders in the dental benefits landscape whose activities and products affect the administrative costs of a dental practice. The goal, Dr. Kessler said, is to bring practical solutions to existing inefficiencies.

The ADA has been very active at the federal level in supporting HR 372, the Competitive Health Insurance Reform Act, which would amend the McCarran-Ferguson Act. Currently, the McCarran-Ferguson Act exempts insurance companies, including dental carriers, from some antitrust laws. The ADA believes these exemptions have resulted in a general absence of scrutiny of insurance companies by the federal government. The ADA is also advocating for non-covered services and assignment of benefits legislation both at the state and federal level.

Ongoing projects for the council include further development on model legislation for states in order to help them with advocacy efforts, Dr. Kessler said, as well as the recent House of Delegates resolution, Resolution 25H-2018, that will explore the creation of a data registry that seeks to position the Association as the arbiter of comprehensive data to support the development of health policy, treatment guidelines, medical necessity rules and to define population health and quality of care.

"Patient care is at risk if payers with large amounts of aggregated data are allowed to dictate treatment guidelines and medical necessity rules," said Dr. Christopher Bulnes, chair of the ADA Council on Dental Benefit Programs. "An ADA clinical dental data repository would help dentists improve on treatment and outcomes of patient care."

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.