Association moves to develop unified system to verify coverage, obtain cost estimates in real-time

The Association wants to identify a solution to the problems dentists currently face regarding eligibility and benefits verification by assessing the feasibility of implementing a system to allow dental insurance companies to provide dentists with accurate information regarding a patient’s dental benefits through an online portal or app.

As a result, the ADA Council on Dental Benefit Programs is acting upon a directive from the 2020 House of Delegates to assess the development of a simplified system to verify coverage and obtain patient cost estimates in real-time before treatment begins.

The resolution, Res. 102H-2020, directs the appropriate agencies within the ADA to investigate the feasibility of developing a platform to allow third-party payers to provide dentists with accurate and timely information regarding a patient’s current dental benefits through a single unified system. The resolution also requires a report with recommendations be prepared for the 2021 House of Delegates.

The ADA Practice Institute’s Center for Dental Benefits, Coding and Quality sent a request for proposals (RFP) to vendors the week of Jan. 4 to find a company that understands the root causes of the problems dental offices face in not receiving complete, current and accurate eligibility and benefits information, as well as to determine the viability of establishing a system that would resolve these underlying issues.

According to the RFP, “In an ideal state, if there were no problems with verifying eligibility and benefits, dental offices would request and receive information in real-time regarding a patient’s eligibility under a dental plan and information on the availability of benefits, i.e., coverage and cost on specific procedures down to the individual procedure/tooth level. This would then provide such information upfront to the patient and avoid unanticipated charges following treatment. The interface between the dental office and the payer would be consistent. The manner and format for requesting information is always the same, and information in the response is always the same.”

Randall Markarian, D.M.D., chair of the ADA Council on Dental Benefit Programs, said that if there is a unified system for benefit verification, a dentist will be able to better inform their patients about what the third-party payer will cover. It will also prevent retroactive denials for times when the dental benefit company mistakenly pays for a service that should not have been covered, he added.

Dr. Markarian said that while the solution won’t be immediate, members should know that the process is in motion.

“I would love to see the ADA either develop a system or partner with a company to provide this service to members,” he said. “It may take three to five years to get a fully functional system, but the benefit to dentists will be worth the wait.”

Organizations interested in responding to the RFP may request a copy by emailing dentalbenefits@ada.org .

For more information on dental benefits, visit ADA.org/dentalinsurance .