Comprehensive ADA Policy Statement on Inappropriate or Intrusive Provisions and Practices by Third Party Payers

The American Dental Association opposes interference in the treatment decisions made between doctor and patient. Plans which contain inappropriate and intrusive provisions substitute business decisions for treatment decisions made through a patient-doctor dialogue. Such provisions and practices deny patients their purchased benefits and robs them of their rights as informed consumers of healthcare.

Plans which contain provisions, such as those listed below, should disclose them to the plan purchasers and to patients. Dentists should be made aware of these practices when offered a contract.

The ADA is of the opinion that a list of practices by third-party payers that are inappropriate or intrusive and interfere with the doctor-patient relationship includes but is not limited to the following:

Bad Faith Practices: Not treating a beneficiary of a dental benefit plan fairly and in good faith; or a practice which impairs the right of a beneficiary to either receive the appropriate benefit of a dental benefits plan, or to receive the benefit in a timely manner.

Some examples of potential bad faith practices include, but are not limited to:

  • failure to properly investigate the information in a submitted claim
  • unreasonably and purposely delaying or withholding payment of a claim
  • withholding funds from bulk benefit payments for services rendered to unrelated patients as a means of settling disputes over prior claims experienced with the dentist either from an alleged past overpayment by the plan or retroactive ineligibility of benefits for a patient

Inappropriate Fee Discounting Practices: Requiring a dentist, who does not have a participating provider agreement, to accept discounted fees or be bound by the terms and conditions set forth in the participating provider contracts signed by other dentists.

Some examples of inappropriate fee discounting practices include, but are not limited to:

  • Issuing reimbursement checks which, upon signing, result in the dentist accepting the amount as payment in full
  • Using claim forms which, upon signing, require the dentist to accept the terms of the plan’s contract
  • Issuing documentation that states the submittal of a claim by a dentist means that he or she accepts all terms and conditions set forth in the participating provider contract
  • Sending communications to patients of nonparticipating dentists which state the patient is not responsible for any amount above the maximum plan benefit

Lowering Patient Benefits and Claims Payment Abuse: Intentionally lowering the benefit to the beneficiary and/or lowering the allowable amount to the dentist negating the code for the actual services performed by the dentist. These practices, coupled with contractual clauses that require the dentist to accept the plan payment as payment in full, compound the problem.

Some examples of claims payment abuse include, but are not limited to:

  • Downcoding: using a procedure code different from the one submitted in order to determine a benefit in an amount less than that which would be allowed for the submitted code
  • Bundling of Procedures: the systematic combining of procedures resulting in a reduced benefit for the patient/beneficiary
  • Limiting Benefits for Non-Covered Services: mandating a discounted fee for procedures for which the plan pays no benefit
  • Least Expensive Alternative Treatment Clauses: contractual language that allows a plan to only pay for the least expensive treatment if there is more than one way to treat a condition
  • Most Favored Nation Clauses: contractual language that requires a dentist to give the beneficiaries of a dental plan the same lower fee that the dentist may have charged another patient

Disallowed Clauses: Contractual language that prohibits a dentist from charging a patient for a covered procedure not paid for by the benefit plan.

Some examples of disallowed procedures include, but are not limited to:

  • Direct and indirect pulp caps when provided in conjunction with the final restoration or sedative filling for the same tooth
  • Frequency limitations such as sealants, which are repaired or replaced by the same dentist within two years of initial placement

Using Non-Dentist Personnel for Adjudication of Benefit: A practice where a non-dentist determines the medical necessity for benefit adjudication. Any determination of medical necessity for the purposes of benefit adjudication should only be made by a dentist licensed in the state in which the procedures are being performed.

Restricting Dialogue between Dentists and Patients or Public Agencies: Contractual language that restricts dentists from fulfilling their legal and ethical duties to appropriately discuss with patients, other health care providers, public officials or public agencies, any matter relating to treatment of patients, treatment options, payment policies, grievance procedures, appeal processes, and financial incentives between any health plan and the dentist.

Automatic Assignment of Participating Dentist Agreements: Contractual language which allows PPO leasing companies and third-party payers to obligate the dentist to participate in any other third party payer or managed care network without full disclosure of fees, processing policies and written consent from the dentist. This is typically accomplished by selling or providing the discount rate information to any other third-party payers and/or other managed care networks.

Non-Disclosure of fee schedules and processing policies prior to contracting: Requiring a dentist to evaluate a contract with a carrier without full disclosure of the fee-schedules and processing policies as it applies to all plans administered by the carrier.

Download Comprehensive ADA Policy Statement on Inappropriate or Intrusive Provisions and Practices by Third Party Payers.