ODA MEMBER DENTISTS ESTABLISHING RELATIONSHIPS AND MAKING A POSITIVE DIFFERENCE WITH DENTAL INSURERS AND OHIO MEDICAID
“You win with people.” – Woody Hayes
While Woody Hayes’ famous quote is often associated with football, it is also very applicable to other sports, business and most other endeavors, including the world of dental insurance and third-party payment.
It applies to dental insurance when you consider that no matter how accurate, diligent and efficient dental office billing staff or dental insurance administrators are, there are always going to be problems and/or misunderstandings that can range from minor annoyances to larger, more costly and frustrating situations. It is at these times or when the dental office is unable to resolve a problem on their own that the Ohio Dental Association, American Dental Association and local dental society can be of assistance.
Institutional credibility of the ODA with dental insurers and Medicaid, coupled with individual personal relationships between the ODA volunteer dentists and ODA staff with individual policymakers and decisionmakers within many Ohio based dental insurance companies, Ohio Department of Medicaid, General Assembly and the governor’s office can be brought to bear on different issues to assist individual practitioners and/or the profession as a whole.
“Most individual dentists don’t have the ability to simply pick up the phone to call decisionmakers at Medicaid or various dental insurance companies to resolve all of their problems on their own,” said Dr. Tracy Poole-Swerlein, chair of ODA Council on Dental Care Programs and Dental Practice. “ODA volunteer member dentists and ODA staff have developed relationships over the years with many of the payers we deal with on a regular basis and are able to use those relationships to assist individual member dentists address problems they’re unable to resolve on their own.”
Medicaid
The ODA Medicaid Working Group, Council on Access to Care and Public Service, Executive Committee and grassroots dentists work to address issues related to the Medicaid program on behalf of both individual dentists who are having problems resolving issues and the profession as a whole.
Within the last few years, the ODA and Ohio Department of Medicaid (ODM) worked successfully together in addressing a number of issues that served as roadblocks to dentists’ participation in the Ohio Medicaid program.
ODM created the Episodes of Care Program as part of its efforts to improve quality of care through value-based payments for the treatment of a wide variety of medical services and two dental services (extractions and opioid prescriptions). The program unfortunately created unintended consequences which resulted in many Ohio dentists receiving judgments that they had to repay the state and/or Medicaid HMOs significant sums of money ranging from thousands of dollars to over $39,000, to over $40,000 and in one case even over $64,000.
Intervention by the ODA and willingness on the part of ODM to address the situation resulted in no reports of dentists having to repay any money and statements from ODM officials that if the dental component of the Episodes of Care Program moves forward in the future extensive communication efforts will be conducted with Ohio’s dentists to ensure everyone fully understands the program and the expectations associated with it.
When the ODA brought to ODM’s attention problems the ODA identified with how Multiple Procedure Reduction Pricing (MPPR) was being applied to Medicaid fee-for-service dental claims last year, ODM responded immediately. The department identified that Centers for Medicare and Medicaid Services (CMS) resource-based relative value scale (RBRVS) data that Medicare uses for payment of physician services was being incorrectly applied to dental claims and took immediate steps to fix the problem and restore the correct reimbursement amounts to all affected dentists. (MPPR is used by government and many commercial insurers in cases where a health care provider performs multiple procedures during a single patient encounter to typically pay “full price” for only the highest-valued procedure while reducing reimbursement for the other procedures that were provided during the same patient encounter.)
Earlier this year, the ODA and the Ohio Academy of Pediatric Dentistry contacted ODM concerning coding practices and reimbursement levels for dental treatment that must be provided in hospital or ambulatory surgical center operating room settings for patients whose extensive dental needs require the use of anesthesia, the majority of whom are covered by Ohio Medicaid. ODM’s very timely response in favorably addressing both the coding and reimbursement issues should help increase access to care for many children who need dental services under general anesthesia.
The ODA Medicaid Working Group is currently in the process of contacting ODM to address issues of concern and ways to improve the administration of the Medicaid program.
“The ODA has established an excellent track record of working with policymakers in both the public and private sector to improve the state’s Medicaid program,” said Dr. Jennifer Kale, chair of the ODA Medicaid Working Group. “This has created very tangible results that have directly benefited every Ohio dentist who treats patients covered by Ohio Medicaid as well as those who decide to become a Medicaid provider in the future.”
93% Medicaid Fee Increase
Years of hard work by grassroots ODA member dentists, the ODA lobbying team, ODM, Gov. Mike DeWine, the Ohio General Assembly and other oral health care advocates culminated in an average 93% increase in Medicaid fees that took effect at the beginning of the year. It was the first significant Medicaid dental fee increase in Ohio in nearly a quarter of a century and one of the largest across the entire country. The volunteer member dentists who serve on the ODA’s Medicaid Working Group along with the ODA staff and professional lobbying team worked with ODM officials to ensure all of the funding that was approved in the state budget was directed towards patient care in the form of increased fees and not plan administration.
Based on the number of calls to the ODA from member dentists since the start of the year, it is clear that many dentists are now considering incorporating more patients covered by Ohio Medicaid into their practices. Other callers have indicated the new Medicaid fees are comparable to or better than many of the preferred provider organizations (PPOs) they participate in. Some have even reported that they have been able to leverage the Medicaid fee increase into better reimbursement from some of the PPOs they contract with.
Dental Insurance
Volunteer dentists who serve on the Executive Committee, Council on Dental Care Programs and Dental Practice (CDCPDP) and Dental Insurance Working Group (DIWG) address third-party payment issues confronting Ohio dentists on both an individual and collective basis. Their actions also help formulate the policies that drive the ODA’s advocacy efforts.
Every month the DIWG meets to address dental insurance related questions, concerns and complaints that are submitted by ODA member dentists seeking help on matters they are unable to resolve on their own. It is comprised of volunteer general dentists and specialists who also serve on the CDCPDP.
The working group’s assistance to individual member dentists has ranged from persuading insurance companies to reverse adverse claim determinations to obtaining clarifications on insurance decisions to providing dentists with public relations “cover” or assistance with adversely affected patients to educating practitioners on more appropriate claim submission practices.
ODA members who would like to utilize the working group’s services may do so by submitting the details of the case to the ODA via the ODA website (https://www.oda.org/member-center/resources/dental-insurance-assistance/), email (dentist@oda.org), fax (614-486-2893) or mail (1370 Dublin Road, Columbus, Ohio 43215). Everything that was submitted to the insurance company and the carrier’s responses should be submitted to the ODA, e.g., a description of the situation, claim, appeal, denial (complete EOB), photographs, radiographs, charting, clinical findings and relevant notes (e.g., if the patient was in pain or sensitive to hot or cold or had bite sensitivity), etc. All patient identifiers should be redacted from everything that is submitted to the ODA.
The Dental Insurance Working Group’s services are free of charge but only available to ODA member dentists.
“The Dental Insurance Working Group has worked hard over the years to address dental insurance matters of direct concern to many individual dentists,” said Poole-Swerlein. “Its services are a tremendous membership benefit and I encourage ODA members to take advantage of this service when they encounter dental insurance problems that they are unable to resolve on their own.”
On a larger scale, ODA representatives have met in recent years with representatives of major insurers and third-party payers including Avesis, CareSource, Cigna, Dental Care Plus Group, DentaQuest, Centene Dental Services (formerly known as Envolve Dental), Liberty Dental, Medical Mutual, Ohio Department of Medicaid, Superior Dental Care, Sun Life and United Healthcare on a variety of issues. The CDCPDP is currently scheduled to meet with Delta Dental of Michigan, Ohio, and Indiana during its July meeting.
“Positive relationships with a number of dental insurers have resulted in significant gains for Ohio dentists. We believe our direct interactions over time helped lead to Delta Dental’s decision to increase its reimbursement levels at a time when other networks were aggressively cutting theirs, Sun Life’s decision to phase out the Dental Care Plus Group withhold and DCPG’s decision to enact more practical and user-friendly crown and core buildup claim review criteria,” Poole-Swerlein said. “These actions resulted from the relationships we’ve developed over the years and the willingness of the insurance companies and the ODA to work together to address issues of mutual concern.”
Poole-Swerlein also noted the ODA formally objected to the fee cuts that Aetna and Cigna put forward for dentists in their PPO networks.
Dental Insurance Legislative Advocacy
Another larger scale project that will benefit thousands of Ohio dentists involves legislative advocacy efforts to enact non-covered services legislation.
Senate Bill 115, introduced by State Sen. Kirk Schuring and cosponsored by State Sens. Bob D. Hackett and Jerry C. Cirino, and House Bill 160, introduced by State Rep. Nick Santucci and cosponsored by State Reps. Tim Barhorst, Gary Click, Rodney Creech, Jon Cross, Thomas Hall, Brett Hudson Hillyer, Brian Lorenz, Mike Loychik, Thomas F. Patton, Phil Plummer, Sharon A. Ray, Brian Stewart and Tom Young, would prohibit insurance companies from dictating the fees that contracting dentists may charge for services that are not covered by the patient’s dental benefits plan. In addition to the abovementioned legislators, State Rep. Al Cutrona, chairman of the House Health Provider Services Committee, has led an effort to move this legislative initiative further along in the legislative process than ever before.
The legislation seeks to undo unfair contract provisions that can unnecessarily interfere with a patient’s relationship with their dentist. In some cases, the imposed reimbursement level is too low to meet the dentist’s actual costs of providing care, leaving the practitioner unable to perform the procedure. Even if the patient wishes to remain with the practice and offers to pay the dentist’s usual and reasonable fee, accepting that offer could put the dentist in breach of their participating provider agreement. This forces the patient to either seek treatment from another dentist who is not under contract or forgo the procedure altogether.
Passage of this initiative has been and continues to be a legislative priority for the ODA’s elected leadership, dentists who participate in the ODA Day at the Statehouse, grassroots member dentists and professional legislative advocacy team who are working to enact it in the face of powerful opposition that includes major insurance companies, labor unions and business organizations.
Contract Analysis Service
Organized dentistry continues to offer the Contract Analysis Service as a no-cost service that assists member dentists in understanding terms and obligations of contractual agreements with dental insurers. It takes contract legalese and translates it into easy-to-understand language and identifies potentially problematic contract provisions and their possible impact on the dental practice. This information can help the dentist either negotiate more favorable contract terms or at least have a fuller understanding of what to expect as a result of entering into the agreement.
To utilize the Contract Analysis Service, ODA members simply have to contact the ODA Department of Dental Services (800-282-1526 or dentist@oda.org) and request an analysis of the contract they are considering. If the contract has already been analyzed, then its analysis will be sent to the member at no charge. If the contract has not been previously submitted to the ODA for review, then the dentist will be asked to send the ODA an unsigned copy of the contract and any accompanying documents. The ODA will then forward it to the American Dental Association where the ADA’s attorneys will analyze it. The ADA will return the completed analysis to the ODA, which will then provide it to the member dentist, again at no charge.
In-office Dental Plans or Membership Plans
In-office dental plans or membership plans provide alternatives to traditional dental insurance and third-party discount plans. They allow dentists to offer uninsured patients the ability to join the plan and pay a monthly or yearly fee directly to the dental practice in exchange for services and discounts created by the dentist. The ODA Services Corp. (ODASC) endorses DentalHQ, a platform that helps dentists create, customize and automate their in-office membership plans. With the DentalHQ platform a dentist has total control over setting the fees and enrolling patients and allows for easier member management and payment options.
To learn more, sign up for a free web demo, and enroll in the ODA Services Corp. in-office membership plan powered by DentalHQ, visit https://www.dentalhq.com/ohio. ODA members receive discounts off DentalHQ’s monthly and management fees along with a 45-day free trial and no set up fees.
Utilizing ODA Member’s Only Resources
ODA staff can be reached by phone (800-282-1526), fax (614-486-0381) or email (dentist@oda.org) to answer questions, provide direction, resources and assistance. With nearly 90 years of combined experience, the ODA staff have the dental insurance expertise, institutional knowledge, legal expertise and oftentimes personal contacts to assist members and/or their offices successfully address confounding dental insurance problems, issues and questions.
If an issue is beyond the ODA staff’s ability to address or requires a more formal response, then member dentists can utilize the services of the DIWG or the Medicaid Working Group. The DIWG meets the second Tuesday of each month while the Medicaid Working Group meets on an as needed basis.
ODA members who would like to utilize either of the working groups’ services should submit their question, concern or request for assistance along with supporting documentation that does not include patient identifiers (e.g., a description of the situation along with all of the information the dental office submitted to and received from the insurance company including claims, photographs, radiographs, charting, appeal, explanation of benefits, etc.) to the ODA (www.oda.org; 1370 Dublin Road, Columbus, Ohio 43215; 614-486-0381 FAX; or dentist@oda.org). All patient identifiers must be redacted from the information that is submitted to the ODA to avoid HIPAA complications.
