VOLUNTEER ODA MEMBER DENTISTS MAKING A DIFFERENCE ON DENTAL INSURANCE AND MEDICAID ISSUES
Volunteer dentists are continuing to assist Ohio Dental Association member dentists and their offices in addressing dental insurance and other third-party payer matters. They predominately serve on the ODA’s Executive Committee, Council on Dental Care Programs and Dental Practice (CDCPDP), Dental Insurance Working Group (DIWG) and Medicaid Working Group and are responsible for addressing the third-party payment issues that confront Ohio dentists on both an individual and collective basis.
Privately Funded Dental Insurance
Every month the Dental Insurance Working Group 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.
The working group’s past actions on behalf of individual member dentists and the profession as a whole have resulted in a wide range of outcomes, ranging from:
- Persuading insurance companies to reverse their adverse claim determinations.
- Clarifying their decisions and/or claims payment policies.
- Addressing more company-wide practices.
- Addressing procedure code revisions.
- Providing dentists with public relations “cover” or assistance with adversely affected patients.
- Educating practitioners on more appropriate claim submission practices.
- Developing recommendations for future ODA legislative initiatives.
On a larger scale, the ODA has met in recent years with representatives of major insurers and third-party payers including Avesis, CareSource, Dental Care Plus Group (DCPG), DentaQuest, Envolve Dental, Medical Mutual, Ohio Department of Medicaid, Superior Dental Care and Sun Life on a variety of issues.
“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 and Sun Life’s decision to phase out the Dental Care Plus withhold,” said Dr. Tracy Poole-Swerlein, vice chair of ODA Council on Dental Care Programs and Dental Practice. “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 also noted the ODA formally objected to the fee cuts that Aetna and Cigna put forward for dentists in their PPO networks and is now in the process of setting up a meeting with Cigna to discuss it and other matters of mutual concern.
When DCPG made crown and core buildup claim review criteria changes that caused much confusion and controversy, particularly among dentists in the Cincinnati area, the ODA expressed its concerns to DCPG. The ensuing interactions between the ODA and DCPG helped result in DCPG’s enactment of more practical and user-friendly criteria.
Dental Insurance Legislative and Marketplace 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 co-sponsored by State Sen. Bob Hackett, and House Bill 160, sponsored by Rep. Nick Santucci, 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.
It 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, 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.
The ODA is developing a Dental Benefits Education Program to provide ODA members and their staff with information on dental benefits issues in hopes that they will use this information to in turn make their patients/subscribers and employers better informed dental benefit consumers. The program will also be used to contract with a dental benefits broker or agent to serve as a trusted person who will follow up on leads (i.e., employers or other dental benefits plan sponsors) provided to the ODA by member dentists. The broker will be responsible for educating employers referred to them about the ODA’s stand on dental benefit plan criteria.
Contract Analysis Service
Organized dentistry continues to offer the Contract Analysis Service as a no-cost benefit 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.
Publicly Funded Dental Insurance (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.
Last year, the ODA and Ohio Department of Medicaid (ODM) worked together successfully in addressing issues associated with the application of the Episodes of Care Program to Ohio dentists. The program 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.
“ODM’s transition to its new system on February 1 has proven to be very challenging for all involved,” said Dr. Jennifer Kale, chair of the ODA Medicaid Working Group. “We have been in contact with the multiple entities involved from ODM to the Medicaid HMOs to the companies that administer the dental benefits for the HMOs concerning the problems that dentists have endured with the new system and will continue to work with them in hopes of getting everything resolved in as timely a manner as possible.”
The ODA is also interacting with companies like Avesis that are seeking to establish a footprint in Ohio as a new administrator for Medicaid HMO dental benefits with a goal of establishing working relationships while also favorably influencing the plans they intend to offer to Ohio dentists.
Medicaid Fee Increase
The overall Medicaid dental program has only received a 1% fee increase since the year 2000. The program’s current reimbursement rates are not competitive with the dental benefits marketplace and do little to nothing to entice dentists to increase their participation in either the Medicaid fee-for-service or managed care programs.
Obtaining a fee increase has been a priority for the ODA and was one of the focuses of the dentists who participated in this year’s ODA Day at the Statehouse. These public efforts along with behind the scenes work by the ODA’s lobbying team have resulted in proposed funding to increase Medicaid dental fees by more than $200 million annually in the state budget bill that is pending before the Ohio General Assembly.
“While there is still much work to be done, we are confident the legislature will allocate funding to significantly increase dental fees effective Jan. 1, 2024,” Kale said. “We also anticipate once the funding is allocated that ODM and the ODA will work closely together to determine the actual fee for each Medicaid covered service.”
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 over 85 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 to 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.
