ADA responds to No Surprises Act request for information

Comments to CMS address advanced explanation of benefits, good faith estimates requirements

The ADA believes that requirements related to advanced explanation of benefits should be applicable to dental plans as they work in concert with good faith estimates for the benefit of both patients and providers.

That was one of the key takeaways from the ADA’s response to the Centers for Medicare & Medicaid Services request for information on the advanced explanation of benefits and good faith estimate requirements of the No Surprises Act. The No Surprises Act, also known as surprise billing, is a new law designed to give consumers more billing protection. The ADA’s comments emphasized the unique challenges dental offices face when implementing these requirements.

In the Nov. 14 response, ADA President George R. Shepley, D.D.S., and Executive Director Raymond A. Cohlmia, D.D.S., also asked CMS to consider the following:

The role of dental plans
In answering what approaches CMS should consider before applying requirements, the ADA said it “strongly believes and encourages” that requirements related to advanced explanation of benefits be applicable to dental plans as they work together with good faith estimates for the benefit of the individual and provider.

To illustrate this, the ADA said if an individual with a dental benefit comes to a dentist, the dentist does not know what, if any, of that patient’s covered benefit has already been utilized, but even if basic assumptions can be utilized to provide a very rough good faith estimate, it’s not possible to be accurate within $400 if the dental plan ends up denying coverage after the fact. The patient will also often not know the details of their plans or the benefits that they have already used for that year. The advanced explanation of benefits is necessary for dental plans to provide to the patient and must go together with the provider good faith estimate.

“It is not appropriate to require dental practices to have to issue a good faith estimate to the carrier when the carrier has no obligation to issue an advanced explanation of benefits to the patient,” the ADA said.

Provider burden
In regard to supporting the ability of providers and facilities to exchange good faith estimate information with plans, issuers and carriers, the ADA reminded CMS that the majority of dental practices currently do not use electronic health record systems. Instead, many dental offices use electronic dental records and practice management systems that are unlikely to be certified by the Office of the National Coordinator for Health Information Technology. The ADA  encouraged the office to review its certification program and “address gaps within this program to move the dental practice management technology toward improved interoperability and data exchange.”

The ADA also shared its concerns that many providers who work for small practices may have difficulty in complying with technology requirements for the exchange of advanced explanation of benefits and good faith estimate data.

“While there have been some shifts in the composition of practice ownership in the dental industry, small practices constitute a large group of dental businesses. These small practices operate on dental software products which meet the minimum requirements for daily operation and care delivery,” the ADA said. “New technology requirements are likely to increase costs for these practices, as vendors will pass the financial burden on to the providers in the form of fees for additional features, new releases and subscription services. These additional costs, in addition to the disruption of implementing new software and the loss of administrative time for training, lead to a significant burden on the practice and may prohibit providers from participating in programs that are tied to such requirements.”

The Association added that it believes that significant federal incentives and investments are needed to promote use of these standards by the dental practice management software industry before requirements are placed on dental offices.

Coding guidance
Regarding coding, the ADA said it appreciates CMS guidance but noted that dental claims are usually adjudicated without consideration of diagnosis codes. The ADA requested further guidance in clarifying if diagnosis codes would be applicable for good faith estimates and advanced explanation of benefits in cases of patients with a dental benefit.

Other considerations
The ADA applauded the efforts of the Departments of Labor, HHS, and Treasury, as well as the Office of Personnel Management, in promoting the use of a Fast Healthcare Interoperability Resources-based application programming interface for advanced explanation of benefits and good-faith estimates transactions. However, most dental practice management and record systems have limited adoption of Fast Healthcare Interoperability Resources. The Association said it is continuing to work with Health Level Seven workgroups on developing dental content in various standards and would “support incentives and significant investment in dental-specific Fast Healthcare Interoperability Resources-based pilots and technology to move the dental industry towards Fast Healthcare Interoperability Resources-based application programming interfaces for real-time exchange of advanced explanation of benefits or good-faith estimates data in the near or mid-term future.” The ADA also encouraged CMS to look into applicable dental data elements in the United States Core Data for Interoperability before promoting the use of Fast Healthcare Interoperability Resources for dentistry.

Read the ADA’s response in full here.

Follow all the ADA’s advocacy efforts at ADA.org/Advocacy.