Dental plan transparency continues to drive advocacy efforts

A new California law is requiring dental benefit companies to be more transparent about the leasing of dental networks, making California the 20th state to pass or amend such legislation.

Dr. Markarian

Dental benefit companies routinely contract with dentists who belong to preferred provider organizations, or PPOs, where patients enrolled in the plan are encouraged to select a provider from the network and the benefit administrators then pay a predetermined amount for covered procedures. In provider network leasing arrangements, the dental benefit company sells or rents its provider network to another company. Without laws requiring notification, the dentist has no knowledge of the transfer and might never be informed until such time that the dental office files a claim only to receive a payment based on a discounted fee schedule.

“Undisclosed leased networks impede dentists’ ability to knowledgeably advise patients on treatment costs and assist with dental
care financing,” said Dr. Randall Markarian, chair, ADA Council on Dental Benefit Programs. “The ADA and the council are pleased that lawmakers are addressing this.”

Dr. Reynolds

In California, Assembly Bill 954, sponsored by the California Dental Association, went into effect in January. Among its provisions, it requires dental benefit companies to name the parties that will have access to a provider contract. It also, gives dentists the ability to “opt out of having their existing provider agreement leased to other entities without impacting their original plan contract.”

“Contracting with dental plans can be a challenge for any dental practice, and now that plans are increasingly leasing their dental networks to third parties, the ability to provide a treatment plan and accurate treatment costs to the patient is more difficult and can have an unintended impact on the dentist-patient relationship,” said Dr. Jim Wood, a dentist and chair of California’s Assembly Health Committee who authored the bill. “If dentists have a more clear understanding of the contract terms, and any updates to those terms, it will better serve the dentist and patient both.”

The California law also states that dental plans are required to maintain an “up-to-date website list of all third parties that have access to a provider network contract and to update that information at least once every 90 days.” The plans must also “clearly identify” the contractual clause that allows network leasing and “identify the source of the discount on all written or electronic remittance and the name of the plan that the dentist has a direct contract with,” according to the summary from the California Dental Association.

Dr. Wood

Improving dental benefit program best practices in regards to leasing was the “primary legislative task” for the Virginia Dental Association in 2019.

California is not the only state that passed legislation on this in 2019.

Last March, with advocacy from Virginia Dental Association, House Bill 1682 passed the state’s House and Senate chambers unanimously and was signed into law.

The Virginia bill’s provisions include limiting the ability of carriers “to sell or otherwise grant access, as provided in a dentist's or oral surgeon's provider contract, to a third-party carrier” and also states that such access may only be allowed if it is “expressly permitted by the provider contract and notice is given to the affected participating providers.”

"I think that for us we had overwhelming support in the legislature because the bill provides fairness and transparency. It's proactive provider notification; it's a front-end patient notification and back-end notification to providers and patients and it just makes sense,” said Virginia Dental Association President Elizabeth Reynolds.

Dr. Reynolds attributed the bill’s successful journey to the state association members' grassroots advocacy —from making calls to walking the hall of the state capital.

“We have a very good relationship with our legislature overall just because when we bring bills, they tend to be very oriented toward patient protection. So I think that legislature tends to see us as friendly as opposed to being self-serving,” Dr. Reynolds said.

The bill went into effect in July 2019.

"Because we were proactive, the insurance companies didn’t have a chance to get their feet on the ground here,” Dr. Reynolds said.

Other states that have adopted or amended existing laws limiting the ability of carriers to lease or sell their networks include Arizona, Arkansas, Connecticut, Florida, Georgia, Illinois, Indiana, Louisiana, Missouri, New Jersey, Nevada, North Carolina, Ohio, Oklahoma, Rhode Island, Tennessee, Texas and Utah.

For more information, visit the ADA’s Center for Professional Success, which has resources available on third party payer advocacy issues