September 20, 2021
Editor’s Note: Dental Insurance Hub is a series aimed at helping dentists and their dental teams overcome dental insurance barriers so they can focus on patient care.
Working closely with the ADA, the state dental society’s advocacy efforts resulted in nearly 100 dental insurance reform proposals in state legislatures during the 2020-21 season.
A total of 26 major dental insurance reform bills have been passed in 16 states.
“As the leading advocate for oral health in the United States, the ADA works tirelessly to influence public policies affecting the practice of dentistry and the oral health of the American public,” said David White, ADA Government Affairs Council DDS Chairman. âIn Washington, DC, the ADA is lobbying Congress and the administration, fighting for things that matter to dentists and the patients they serve. The ADA also provides advocacy advice and technical support to help crown dental corporations advance their respective policy agendas.
The following is just a small sampling of the legislative victories that the ADA and crown corporations have advocated for in 2020 and 2021.
In Beehive State, Dental Insurance Reform Law HB 359 requires full transparency of dental insurers’ policies, which must include a summary of any significant changes to the plan since the last policy update and a description of their encoding and grouping fonts.
Insurers are prohibited from under-coding in a way that prevents a dentist from receiving, either from the plan or from the patient, a fee for the service actually rendered.
It also prohibits insurers from bundling so that a procedure code for a service is labeled as non-billable for the patient. However, bundling is allowed if the procedure code relates to a service that can be provided in conjunction with another service.
Explanations of benefits should include the reason for any downcoding or bundling.
In March, the governor of the state promulgated the law HB 1154, relating to the prior authorization of dental services, the leasing of the network of providers and the retroactive refusal of payment of claims.
The new law:
â¢ Prohibits dental plans from refusing a claim subsequently submitted by a dentist for procedures specifically included in a prior authorization, unless the refusal is based on specified reasonable circumstances such as a change in the procedure. patient’s condition.
â¢ Prohibits insurers from renting a dentist in their network to another insurer without the knowledge and permission of the dentist, and the dentist cannot be dismissed from the network of the original insurer for refusing the lease. Dental insurance plans are also required to notify third parties to which they are renting under the new law.
â¢ Prohibits dental insurers from undertaking overpayment recovery efforts more than 12 months after the initial payment of the claim.
In Arizona, two new dental insurance laws came into effect in 2021.
In June, the Governor of Arizona enacted SB 1824, directing the Arizona Department of Insurance and Financial Institutions to prepare an annual medical loss ratio report for each dental insurer operating in the state. . To calculate the medical loss ratio, the ministry must use data submitted by dental insurers in accordance with currently required regulatory documents.
The medical loss ratio indicates the percentage of income that dental insurers spend on actual care, compared to administrative costs.
The second bill signed concerns the assignment of benefits.
Assignment of Benefits laws give patients the flexibility to have their insurance payments made directly to their dentist, whether or not the dentist is part of the insurer’s network.
In February, Arizona enacted HB 2119, which added dental insurers to existing state benefit assignment law. Now, when a patient in Arizona performs an assignment, insurance payments can only be made 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 engaged in anti-competitive behavior and violated federal antitrust laws by allocating operating territories and dividing the domestic market in order to restrict competition and reduce reimbursement rates for dentists. The complaint goes on to allege that Delta’s anticompetitive actions harm both dentists and their patients by limiting the choices of dental care available to patients and by making it more difficult for dentists to provide the care patients need and need. they wish.
In addition to the ADA’s complaint, individual dentists have filed several class actions against Delta, also alleging violations of antitrust laws. In these complaints, the ADA and individual dentists ask the court to certify the proceedings as a class action.
âThe ADA exists to propel the dental profession and to help our members advance the overall oral health of their patients,â said Dr. White. âWe are strong supporters of our members, promoting the art and science of dentistry. Our mission is to ensure that all member dentists have what they need to provide the best possible patient care.
The ADA has a new online hub for out-of-the-box dental insurance information that can help dentists deal with and resolve even their most frustrating questions at ADA.org/dentalinsurance.