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United Concordia Dental moves away from disallowing payment for services

September 10, 2018

By David Burger

Editor's note: This is the 18th 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.

Photo of Dr. Bulnes
Dr. Bulnes
In what can be considered a win for the dentist-patient relationship, United Concordia Dental has just amended its policy on disallow clauses.

The third-party payer now allows dentists to charge patients for previously disallowed services if the dentist has explained to the patient that the service may not be paid for by the plan and the patient consents to the service.

The disallow clause had mandated that even after a treatment a dentist deemed necessary, not only will the third-party payer not pay for the procedure, but the dentist was also prohibited from charging the patient for the procedure.

The decision to change its policy, said Dr. Quinn Dufurrena, United Concordia Dental chief dental officer, was inspired partly by an article written by a staff member of the ADA.

"A recent article by Dr. Dave Preble, senior vice president of the Practice Institute at the American Dental Association, about ethics in dentistry has further heightened United Concordia's focus on promoting open communication between dentists and their patients," said Dr. Dufurrena in a statement to the ADA News. "Our goal is to not interfere with the doctor/patient relationship."

Dr. Dufurrena continued: "We recognize the need for patients to be involved in dental treatment decisions. We encourage dentists and patients to have detailed discussions about proposed treatments, as well as reasonable alternatives. If the information available to United Concordia suggests that the claim be denied for lack of dental necessity, we support the dentist discussing treatment options with the patient. If the patient signs a consent form agreeing to proceed with the treatment and acknowledging the lack of insurance reimbursement for the treatment, a participating dentist can bill the patient. The key is that the provided treatment has been agreed upon by both the patient and dentist."

Dr. Preble's article, "Ethical Considerations in Dental Plan Claims Adjudication," published in the June 2017 edition of The Journal of the American Dental Association, leads off with a question the ADA Council on Dental Benefit Programs received from a dentist: "One question we received was from a member who said that part of his contractual agreement as a participating provider allows dental plans to 'disallow' treatment. This means the plan can prevent him from billing the patient in addition to denying benefits, which essentially precludes him from performing the service even though, in his professional judgment, the treatment is necessary and the patient has been appropriately involved in the decision. Are there ethical issues for the third-party payer, the dental consultant, and me? asked the member."

Dr. Preble was clear in his answer. "A system that results in unilateral interference in the dentist-patient relationship, denying patients their right to involvement in treatment decisions and making those decisions without the necessary information best evaluated by the patient's dentist, is not an acceptable way to protect patients," he wrote in the article. "The policy of disallowing claims should be discontinued as inappropriate and potentially unethical. It does not serve patients well, and it requires dentist consultants, the licensed dentists who evaluate claims for third-party payers, to engage in the questionable practice of making treatment decisions without an adequate informational basis or the necessary dentist-patient interaction. They should limit their decisions to approval or denial of benefits to minimize their risk."

DDB LogoThis is not the first time a third-party payer has rescinded a policy based on input from the ADA. This summer, the Guardian Life Insurance Company of America reversed its position on third molars and associated sedation and anesthesia, now assuring dentists that claims will no longer be reviewed for medical necessity.

After that decision, Dr. Steve Snyder, chair of the Council on Dental Benefit Programs, said, "This is just another example of the ADA advocating on behalf of all dentists nationwide."

"Dr. Preble's article supports the ADA contention that third-party payers are not in a position to determine which services need to be performed and we appreciate UCCI's recognition of this fact," said Dr. Christopher Bulnes, vice chair of the ADA Council on Dental Benefit Programs. "Patient care and treatment decisions should be made in an informed partnership between patients and qualified and duly licensed dental professionals. The ADA has been very active in its opposition to these types of contractual clauses. United Concordia Dental's decision, in light of Dr. Preble's advocacy in JADA, proves once again that the ADA believes in the integrity of the dentist-patient relationship and will fight for it."

The House of Delegates adopted a new policy in 2016 that opposes practices by third-party payers that permit disallowed claims and other practices the Association believes are inappropriate or intrusive. Resolution 12H-2016, Comprehensive ADA Policy Statement on Inappropriate or Intrusive Provisions and Practices by Third-Party Payers, was in response to member dentists continuing to call the ADA with concerns related to managed care agreements that interfere with the doctor-patient relationship.

"The American Dental Association opposes interference in treatment decisions made between the doctor and patient," the policy states. "Plans which contain inappropriate and intrusive provisions substitute business decisions for treatment decisions made through a patient-doctor dialogue. Such provisions and practices deny patients their purchased benefits and robs them of their rights as informed consumers of health care."

The ADA has drafted an informed consent form that dentists can use if faced with a similar situation. The sample consent form can be found at ADA.org/dbfaq and may be customized to meet a dentist's particular needs.

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.