Two new dental benefit guides address common hurdles anticipated when reopening practices

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As dental offices open, they may find that their costs have increased, and find themselves seeing unemployed patients who have lost the coverage they used to have when they were employed.

In the face of these economic challenges, the ADA has released two online guides relating to third-party payment programs available at that are intended to help smooth the path of reopening practices: Handling Contract Negotiations and Handling Eligibility Verification.

Both are brief, to-the-point guides to handling these situations in practices.

The first guide, Handling Contract Negotiations, opens by saying that dentistry faces increasing standards for infection control during and following the pandemic.

“To limit transmission, the ADA has issued interim recommendations aligning with those from the Centers for Disease Control [and Prevention] for infection control and use of personal protective equipment,” according to the guide. “The ADA anticipates that the cost of care will substantially increase for dental procedures. Under these circumstances, dental offices may see the need to readjust their fee schedules.”

 Image of Randall Markarian
Dr. Markarian
The guide goes on to outline how dentists can individually negotiate fee increases with third-party payers, which includes doing homework beforehand to know the information that payers might need to know, such as:

• The desired fee for each procedure code.
• Costs associated with operating your business.
• The date when your fees were last revised.

As the first guide closes, it offers a reminder: “It is good practice to always review your contracted fee schedules annually ... The fee schedules are typically part of the participating provider agreement — a legal contract between the dentist and the third-party payer … It is important to review these documents carefully before trying to project revenues and negotiating fees with the payer.”

“While some payers may not be willing to negotiate, it is important to help them understand that just the cost of the additional personal protective equipment — not including any of the expenses related to additional safety precautions — may result in an added expense of about $15-$20 per patient visit,” said Dr. Randall Markarian, chair of the ADA Council on Dental Benefit Programs.

Dr. Markarian added, “Dentists are equally concerned about the financial difficulties that some of our patients face. However, when third-party payers choose not to cover the additional expense, they must leave the decision to the individual dental office on whether to charge the patient. We believe that it is unfair for third-party payers to refuse to negotiate fees and refuse to allow the office the option to charge the patient for additional overhead costs.”  

The second guide, Handling Eligibility Verification, states that with high rates of unemployment, it is likely that patients coming in for appointments may have recent changes in their employment situation. It is essential, then, that dental offices verify eligibility on the date of service to avoid recoupment requests in the future.

“Often dental offices face recoupment situations because of retroactive changes to eligibility,” according to the second guide. “Third-party payers are able to reflect eligibility changes retroactively and clauses within the participating provider contracts allow them to recoup funds from the participating dentist when treating a patient who has lost benefit coverage. Out-of-network dentists are not contractually obligated to return payments received in this situation; however, it is not uncommon for payers to withhold funds from future payments.”

The second guide goes on to include questions to ask patients during the visit to screen for potential eligibility changes. Sample questions may include the following:

• Since we last saw you, has your dental coverage changed?
• Since we last saw you, have there been any recent employment changes for yourself and/or the policyholder?
• If yes to those questions, did the employer provide you and/or the policyholder with paperwork stating how long the dental plan coverage will remain in effect, or how it might affect your coverage due to this change?

“Documenting the interactions with the payer may assist in any future dispute resolution, although payers generally place the burden on the provider by refusing to reimburse or by clawing back reimbursement already paid,” the second guide states.

Dr. Markarian had a message to his colleagues about verification of eligibility.

“Make sure as you begin to see patients and check insurance some may not be eligible for the plans they had before," he said. "Employers will take longer to communicate employment changes to payers, and in turn, the payers may not have their systems updated to reflect correct eligibility. So use the new guide to ask questions when patients come in so that you don’t potentially increase your financial hardship. If the patient has a new plan, make sure you receive the summary of benefits and understand what services are covered because plan designs are always different.”