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ADA proposes 5 solutions in CMS information request for reducing paperwork

July 31, 2019

By Jennifer Garvin

Baltimore — The ADA is proposing five standards-based solutions to the Centers for Medicare & Medicaid’s request for information to reduce administrative and regulatory burdens on health care providers as part of the agency’s Patients over Paperwork initiative.

“The ADA considers an unfettered patient-dentist relationship as the foundation for ongoing oral health,” wrote ADA President Jeffery M. Cole and Executive Director Kathleen T. O’Loughlin in a July 29 letter to CMS. “Further, this patient-centric relationship is supported by efficient and effective administrative processes that enable the dentist and her or his practice staff to provide necessary care. Paperwork, electronic or otherwise, requires time and resources to compile, complete, file or transmit.”

The ADA told CMS that between Medicaid, Medicare Advantage and the Children’s Health Insurance Program, approximately 87.8 million individuals are covered for some oral health services.

“This volume of patients can be positively impacted were CMS to understand and promote changes to achieve administrative simplifications within the dental care system,” Drs. Cole and O’Loughlin wrote.

In the letter, the ADA addressed five paperwork intensive administrative activities that have standards-based solutions.

Streamlining the credentialing process. Currently, dentists must submit credentialing applications and other related information to numerous dental health plans, dentist employers and other health care organizations for credentialing, screening, revalidation, directories and other data requirements multiple times each year. This number is increased when a Medicaid and/or CHIP program contracts with managed care. The approval process may take as long as six months, which is challenging for dentists and limits access for Medicaid recipients. The ADA is encouraging standardized use of CAQH ProView — a web-based, universal credentialing program —as a means to reduce credentialing paperwork required of any health care practitioner. CAQH is an acronym for the Council for Affordable Quality Healthcare.

Health Insurance Portability and Accountability Act standard eligibility inquiry and response transactions– X12 270 and 271. These transactions were created to eliminate protracted paper-based or telephone interactions. Increasingly, more robust information is being made available from individual payer proprietary internet portals, which has improved efficiencies but also places a new set of administrative burdens on dentists and other health care providers; specifically, the need to learn each payer portal’s login and information presentation format. The ADA believes that a more robust 270/271 transaction set combination can supplant the proliferation of proprietary payer portals and recommends that 270/271 be modified to accept the content described in the National Dental Electronic Data Interchange Council’s Top Dental Eligibility and Benefit Questions Response Guide and recommends that CMS develop a specification that enables “real-time” transmittal and receipt of the 270/271 transaction sets.

Claim submissions. The percentage of electronic claims continues to increase for procedures covered by medical and by dental benefit plans. According to the 2018 CAQH Index, the figures are 95% for medical plans and 79% for dental, while paper claim submissions continue to decrease. The ADA encourages dentists to implement the HIPAA standard electronic dental claim transaction, and for those who continue to submit on paper, to use the current version of the ADA Dental Claim Form. The ADA would like to see that federal guidance concerning consistency in dental claim submission via paper be expanded to include state-funded programs and not limited to federally-funded programs. “When there is no alternative all paper-based dental claims should use the current ADA form,” Drs. Cole and O’Loughlin wrote. “Otherwise, dentists and third-party payers will be faced with the overhead cost and time necessary to support myriad formats.” The ADA would also like the dental community to adopt a HIPAA standard for claim attachments and believes that CMS should use its authority to ensure that processing policies, prior authorization guidelines and attachment requirements are clear and consistent.

Coordination of benefits. The X12 Healthcare Claim Transaction 837 supports several business functions in its various HIPAA specified uses (Institutional, Professional and Dental) – claim or encounter reporting, pre-determination of dental benefits, and coordination of benefits. To reduce paperwork and related administrative time and resources, the ADA recommends that the appropriate federal authority publish regulations that require third-party payers to implement payer to payer coordinator of benefits. This regulation could be initially directed towards managed care organizations that administer state Medicaid programs. “Doing so would have a beneficial ripple effect where implementation for the federally funded program would be expected to affect the [managed care organizations’] commercial sector business,” Drs. Cole and O’Loughlin wrote. Another avenue to promote payer to payer coordination of benefits is CMS’ Administrative Simplification Enforcement and Testing Tool. “Widespread adoption of Payer to Payer [coordination of benefits] is a goal that the ADA sees as a collaborative effort that involves HIPAA-covered entity education, modification of third-party payer processing software, and upgrades to provider practice management software. There are short-term expenses associated with these efforts, all of which lead to achieving greater overall efficiencies through reduction of manual interventions and paperwork.”

Reimbursements. There are two broad categories of administrative issues concerning third-party payer payments to dentists and other health care practitioners for services delivered to patients — the reimbursement mechanism and the reconciliation processes. These reimbursement mechanisms include a mix of technologies: paper checks, electronic funds transfers and virtual credit cards. The ADA supports the continued use of paper checks for dentists who prefer this method, but also strongly encourages that dentists implement the applicable HIPAA standard transactions in order to lower administrative time and costs for reconciliation. The ADA does not support virtual credit cards as a viable payment mechanism, as they simultaneously add to practice administrative costs since new protocols must be put in place to process these reimbursements, and they reduce the amount actually received after accounting for transaction costs and card processing fees. The ADA requests that CMS provide regulations that will permit reimbursement via virtual credit cards “only when specifically requested by a dentist or any other health care provider.” The ADA also noted the need for a universal electronic funds transfer enrollment mechanism since some third-party payers require health care providers to enroll using a proprietary process in order to receive payments electronically. The ADA recommended that CMS open the Remittance Advice Remark Code maintenance process to permit the industry’s full participation, which would be achieved by adopting an external, independent code management process akin to X12’s external code maintenance process.

The ADA concluded by encouraging CMS to appoint a chief dental officer that can speak out on the specific administrative burdens faced by dentists.

“We believe that the agency needs a CDO to oversee the oral health care provided to patients and reduce the administrative burden faced by dentists,” Drs. Cole and O’Loughlin concluded.

Follow all of the ADA's advocacy efforts at ADA.org/Advocacy.