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ADA Council on Dental Benefit Programs advocates for member dentists on dental benefit issues

Close, meaningful contact with third-party payers is essential part of council members’ jobs

April 20, 2021

By David Burger

Two March meetings between third-party payers and the ADA to discuss streamlining the claim adjudication process are the latest example of the Association continuing to advocate for member dentists.

“Meetings with third-party payers are nothing new for the ADA Council on Dental Benefit Programs, which over the years has advocated on behalf of member benefits on dental insurance and benefits issues,” said Randall Markarian, D.M.D., council chair.

 Dr. Bert Oettmeier
Dr. Oettmeier
The council’s Dental Benefit Information Subcommittee members meet with some third-party payers individually each year, and the council chair and vice chair meet with the National Association of Dental Plans annually.

Bert Oettmeier, D.D.S., chair of the council in 2010, said that being in close contact with third-party payers is an essential part of the council members’ jobs, despite often-conflicting opinions.

“Most of what we are interested in is not what they were interested in,” said Dr. Oettmeier.

Christopher Bulnes, D.M.D., immediate past chair of the council, said, “Somewhere, we can meet them in the middle for the benefit of our members.”

Despite occasional differences between payers and the ADA, successes as a direct result of the council’s advocacy include:

• Revising problematic explanation of benefits language so that it does not interfere with the dentist-patient relationship.
• Allowing dental consultants to speak with dentists on a peer-to-peer basis.
• Convincing dental plans to revise problematic processing policies.
• Helping dentists who terminated network participation with leasing companies get correctly paid as out-of-network providers.

Dr. Bulnes said another success was the launch of the Administrative Efficiencies Summit, which took place in 2018 and 2019 and that he hopes continues. The summit, at ADA Headquarters, hosted member dentists, led by the council, initiating a conversation with third-party plan administrators about the pain points of the administrative costs of a dental practice and how they keep them from focusing on patient care.

 Dr. Christopher Bulnes
Dr. Bulnes
The ADA Center for Dental Benefits, Coding and Quality, at the direction of the council, had conducted a front-office survey on administrative burdens that aligned with the summit’s five focal points:

• Patient eligibility and benefits verification.
• Coordination of benefits.
• Electronic funds transfer and electronic remittance advice.
• Claims and attachments.
• Dentist credentialing.

“We wanted to work on those pain points that would bring down the stress levels of dentists and front-office staff,” Dr. Bulnes said.

Ron Riggins, D.M.D, who served as council chair from 2015-17, said that during his time on the council they started to look at both ways they could change the landscape of dental benefits and ways they could help dentists and dental office staff navigate the dental benefits landscape.

“Out of that discussion I think we have seen some really good initiatives at the ADA,” Dr. Riggins said. “One is the support from the ADA on the in-office programs as an alternative to dental benefit plans to help make care more affordable for our patients, especially the elderly. We also started to ramp up the  education on all dental benefits, but particularly on preferred provider organizations and gaining efficiencies administratively in the dental office. A lot of that work still needs to be done to get all the pieces of our electronic world speaking to each other efficiently, but we are making gains.”

Walter Weber, D.D.S., chair of the ADA Council on Dental Benefit Program’s Dental Benefit Information Subcommittee, said that an important current goal of the council is to continue to improve the eligibility process and push for industry standardization of requested attachments.

The subcommittee met with Principal and Humana virtually in March.

“These meetings open a dialogue with insurance companies and have in the past been successful in initiating positive policy changes by the insurance companies,” Dr. Weber said.

The agenda of both meetings included discussions on the need for industry standardization on documentation needed for claim adjudication at the procedure code level and concerns with continued personal protective equipment expenses incurred by dental practices.

“We also discussed the role of artificial intelligence in claims adjudication,” Dr. Weber said. “Both Principal and Humana expressed that there will always be a need for consultants: the human oversight.”

Dr. Weber
Dr. Weber
In addition to improving the current claim adjudication processing system, these meetings focused on industry trends and emerging issues in the payer landscape to ensure that the ADA is informed of what might be coming down the road.

During the Principal meeting, the subcommittee also talked about Principal’s partnership with Onederful, an effort to make it easier for dental offices to verify eligibility and confirm benefits.

The agenda of the Humana meeting also included a discussion on the ADA Credentialing Service, powered by CAQH ProView.

Dr. Weber said ultimately, the end result of these meetings is to help dentists get paid on the first submission of a claim.

“Ideally, the dentist would like real-time eligibility without lengthy phone calls to payers,” Dr. Weber said. “The more the process of eligibility can be simplified, the more likely a claim will be paid on first submission. Streamlining benefits administration should be the goal.”

“An open dialogue with third-party payers is vital to the ADA to be able to effect change on the behalf of our members,” Dr. Riggins said. “CDBP and the ADA staff that support the council have been very successful over the years in mitigating third-party payer administrative burdens or processing policies that would have been detrimental to our members, their practices and ultimately their patients. It is an ongoing and never-ending discussion.”

For more information on educational ready-to-use resources on dental insurance, visit the ADA’s dental insurance website.