Editor’s note: Dental Insurance Hub is a series aimed to help dentists and their dental teams overcome dental insurance obstacles so they can focus on patient care.
Working closely with the ADA, state dental society advocacy efforts have resulted in nearly 100 dental insurance reform proposals in state legislatures during the 2020-21 season.
In all, 26 significant dental insurance reform bills became law in 16 states.
The following is just a small sample of legislative wins the ADA and state societies advocated for in 2020 and 2021.
In the Beehive State, dental insurance reform law HB 359 requires full transparency of dental insurers’ policies, which must include a summary of any material changes to the plan since the last policy update and a description of their downcoding and bundling policies.
Insurers are prohibited from downcoding in a manner that prevents a dentist from collecting, from either the plan or the patient, a fee for the actual service performed.
It also prohibits insurers from bundling so that a procedure code for a service is labeled as non-billable to the patient. Bundling is allowed, however, if the procedure code is for a service that may be provided in conjunction with another service.
Explanations of benefits must include the reason for any downcoding or bundling.
In March, the state governor signed into law HB 1154, related to prior authorization of dental services, provider network leasing and retroactive denial of claim payments.
The new law:
• Prohibits dental benefit plans from denying a claim subsequently submitted by a dentist for procedures specifically included in a prior authorization, unless the denial is based on specified reasonable situations such as change in the patient’s condition.
• Prohibits insurers from leasing any dentist in their network to another insurer without the dentist’s knowledge and permission, and the dentist may not be dismissed from the original insurer’s network for refusing the lease. Dental insurance plans also are required to announce third parties to which they lease under the new law.
• Prohibits dental insurers from initiating overpayment recovery efforts more than 12 months after the original payment for the claim was made.
In Arizona, two new laws regarding dental insurance went into effect in 2021.
In June, the Arizona governor signed SB 1824 into law, directing the Arizona Department of Insurance and Financial Institutions to prepare an annual report on the medical loss ratio for each dental insurer doing business in the state. In calculating the medical loss ratio, the department is to use data submitted by dental insurers in compliance with currently required regulatory filings.
The medical loss ratio shows the percentage of revenue dental insurers spend on actual care, as compared to administrative costs.
The second bill signed relates to assignment of benefits.
Assignment of benefit laws give patients the ability to have their insurance payments go directly to their dentist regardless of whether their dentist is in the insurer’s network.
In February, Arizona enacted HB 2119, which added dental insurers to the state’s existing assignment of benefit law. Now, when a patient in Arizona executes an assignment, insurance payments may be made only to that patient’s dentist.
Delta Dental lawsuit
The ADA also advocates for insurance reform in the legal arena.
The ADA has filed a class action lawsuit against Delta Dental Plans and the Delta Dental Plans Association.
The complaint alleges that Delta has engaged in anticompetitive conduct and violated federal antitrust laws by allocating territories of operation and dividing the national market in order to restrict competition and reduce reimbursement rates to dentists. The complaint goes on to allege that Delta’s anticompetitive acts hurt both dentists and their patients by limiting the choices of dental care available to patients and making it more difficult for dentists to deliver the care that patients need and want.
In addition to the ADA’s complaint, individual dentists have filed several class action complaints against Delta, also alleging antitrust violations. In these complaints, the ADA and the individual dentists are requesting that the court certify the proceedings as a class action.
“The ADA exists to power the profession of dentistry and to assist our members in advancing the overall oral health of their patients,” Dr. White said. “We are strong advocates for our members, promoting the art and science of dentistry. Our mission is to ensure all member dentists have what they need to provide the best possible patient care.”
The ADA has a new online hub for ready-to-use dental insurance information that can help dentists address and resolve even their most frustrating questions at ADA.org/dentalinsurance.