CDA is taking action to help dentists navigate a rapidly-shifting marketplace and to help sustain the financing and delivery systems in which dentists can most effectively provide quality oral health care to their patients.
In August 2013, CDA and several individual dentists filed a legal action against Delta Dental challenging, in part, its attempt to change Premier provider agreements. In response to this action, Delta filed a motion to dismiss the entire matter. After considering the motion, the arbitrators rejected Delta Dental's recent motion to dismiss the entire action, and found that there was sufficient evidence to allow the individual dentists to proceed on their claims that Delta's attempt to change key provisions of its participating dentist agreements violated the legal doctrine of "good faith and fair dealing." The decision will allow the arbitration to proceed.
Although federally required adult dental services have been available to beneficiaries of Medi-Cal, adult optional Medi-Cal dental benefits were eliminated in July 2009, except for beneficiaries who are pregnant or residing in a skilled nursing facility or intermediate care facility. With many benefits for adults restored May 1, the recent CDA Presents lecture in Anaheim titled Adult Denti-Cal Services: Navigating the Renewal Program explained the treatment options and requirements of newly reestablished Denti-Cal benefits for adults. Presenters Tom Holloway, DDS, Nagaraja Murthy, DDS, and Nirmala Prabhu, DMD, offered valuable information concerning common denial codes in treatment authorization requests and claims, ways to reduce unnecessary denials and specific criteria for common restored procedures.
Cigna Dental recently notified contracted providers across the country about upcoming PPO network structure changes and directory enhancements. A May 22 correspondence outlines Cigna's intent to streamline the names of its networks by moving to two network names, rather than the four that currently exist. CDA has expressed concerns with the proposed cost effectiveness designation of dentists to Cigna and is currently working with the ADA and Cigna to learn more about the program and the plan's methodology.
Despite the efforts of dozens of health care organizations including CDA, which have sought at a minimum a reversal of last year's 10 percent reimbursement rate cut for Medi-Cal/Denti-Cal providers, the 2014-15 state budget approved by the Legislature June 15 did not include any reimbursement rate increases. The governor's administration indicated that the increased costs of providing Medi-Cal/Denti-Cal coverage due to the state's expansion of eligibility and higher than expected enrollment have made it more difficult for the state to restore funding for reimbursement rates.
CDA learned in late May that Delta Dental of California began distributing a new Participating Provider Agreement (Commercial Fee-for-Service) to newly contracting California providers. For those newly contracting providers, this new agreement appears to be an all-inclusive provider agreement for both the Delta Dental Premier and PPO products. CDA understands that Delta Dental will no longer offer separate Premier and PPO provider agreements to newly contracting dentists. Along with the new Provider Agreement, newly contracting dentists will receive the Delta Dental Premier Addendum.
CDA received a ruling on April 10 from the arbitrators hearing the case against Delta Dental, who decided that CDA cannot participate as a claimant in the arbitration because CDA itself is not a party to the Premier provider agreement that contains the arbitration clause. However, CDA can still offer legal representation to all dentists who are parties to the binding arbitration and will continue to work with and support them throughout the proceedings.
May 1 marks the date of formal restoration of adult benefits in the Denti-Cal program. CDA offers a few suggestions to help dentists make sure they are prepared for the program to return: familiarize yourself with the benefits available to adults; confirm that you are an enrolled provider in the Denti-Cal program; and attend the lecture that will cover the renewed program at CDA Presents The Art and Science of Dentistry in Anaheim.
Dentists gained firsthand knowledge of practice model selection, contractual analysis, legal implications of claims and more at CDA's Dental Benefits Workshop. Held at CDA's headquarters in Sacramento, more than 70 people, including dentists and staff from 40 practices, attended the March 20-21 event. Attendees were able to earn up to 12 hours of continuing education and improve their skills analyzing and evaluating existing dental plan contract performance in their practices.
CDA’s arbitration with Delta took a step forward on Feb. 25 with a “preliminary hearing” conference call with the panel of arbitrators assigned to the case. The purpose of the call was to schedule dates for different stages of the arbitration. In light of the extensive briefing that has already been submitted by both parties, the panel of three arbitrators has indicated it will likely decide two significant issues by early April.
Nearly five years after the state eliminated dental benefits for adult beneficiaries in the Medi-Cal program, many of those benefits are being restored as of May 1, 2014. This comes largely as a result of the pent up need for dental care, so visibly demonstrated at CDA Cares.
CDA’s legal action against Delta took a step forward with a decision by the American Arbitration Association to select three arbitrators to hear and decide the case. The selection of an arbitration panel meant the case was able to move forward with a preliminary conference scheduled Feb. 25.
Denti-Cal providers received positive news Jan. 9 regarding CDA efforts to stop the state from implementing retroactive reimbursement cuts, which were not included in Gov. Brown’s proposed 2014-15 budget. CDA advocated strongly against the 10 percent “clawback” of payments made since June 2011, citing the devastating impact on the provider network and patients’ ability to access care.
Denti-Cal providers received positive news regarding retroactive reimbursement cuts in Gov. Brown’s proposed 2014-15 budget released Jan. 9. The spending plan does not include a 10 percent “clawback” of payments made since June 2011 when the state authorized Medi-Cal reimbursement cuts as part of its budget.
CDA’s legal action against Delta remains in the preliminary stages, with the parties awaiting appointment of an arbitrator. Delta has requested appointment of a three-arbitrator panel, which delayed the appointment process while the parties attempted to resolve the issue.
The Department of Health Care Services (DHCS) is implementing cuts for Denti-Cal providers that were originally authorized through the state budget process in 2011. Initially, it was thought that the 10 percent rate cut applied to all services provided on and after Sept. 5, 2013. However, recent clarification by the state explained that it is implementing the cuts on all payment checks cut on Sept. 5 and ongoing, even if the services were provided in previous months.
On Oct. 1, Delta Dental of California issued a formal Answer to the Demand for Arbitration. Delta asserts that it has the right to amend Participating Dentist Agreements based on language in the contracts and its notification to the Department of Managed Health Care indicating that it intends to revise the provider agreements.
The registration deadline for CDA’s Dental Benefits Workshop has been extended to Nov. 15. The workshop is intended to help dentists who want to build their business skills and confidence, as well as improve practice profitability when dealing with dental plans.
CDA and a coalition of health care organizations aiming to stop Medi-Cal rate cuts implemented by the state filed a petition with the Supreme Court on Friday. The Petition for Writ of Certiorari asks the Court to reverse the decision by the Ninth Circuit Court of Appeals upholding the rate cuts.
The lengthy arbitration process between CDA and Delta Dental has commenced, with the parties entering into discussions about the selection of an arbitrator. Delta is expected to file a formal response to the demand for arbitration on or before Oct. 1.
CDA’s legal action challenges both Delta’s right to make certain amendments to dentists’ individual contracts and reduce Premier fees unilaterally. CDA will request that the arbitrator, once appointed, maintain the status quo until a final ruling is made in the binding arbitration.
California is reaching the final phases of its transition of the Healthy Families Program (HFP) to the Medi-Cal program. Since Jan. 1, 2013, the children getting health and dental coverage through the HFP have been moving to receive their care through the Medi-Cal program. Approximately 850,000 of the 880,000 children have been transitioned to date. Sept. 1 marked the transition of approximately 8,000 children who live in mostly rural California counties.
CDA’s legal action against Delta Dental of California, filed on Aug. 14, has prompted member questions about the next steps in the process. In order to help members understand the legal action, CDA has prepared a FAQ document. CDA will continue to provide regular updates on developments in the case.
For those dentists who want to build their business skills and confidence, as well as improve practice profitability when dealing with dental plans, there is still time to register for CDA’s Dental Benefits Workshop.
After a series of court decisions upholding the legality of the state’s 10 percent reduction to Medi-Cal provider reimbursement rates, the Department of Health Care Services (DHCS) has announced that it will begin implementing the cuts for Denti-Cal providers on Sept. 5. The Department’s announcement states that the prospective rate reduction will be phased in by provider type, beginning with dental and medical transportation and ending with pharmacies, physicians and distinct-part nursing facilities on Jan. 9, 2014.
On behalf of its members, the California Dental Association — along with several individual dentist providers — has taken legal action against Delta Dental of California by filing a demand for binding arbitration in response to Delta’s notice dated Aug. 1, informing providers of changes to key provisions in their agreements.
In an ongoing series, CDA is profiling members who have taken different approaches to how they practice in order to counter changes in the profession such as an overall drop in adults seeking dental care, the decline in the economy and real estate market, increased regulatory compliance, reduced reimbursement rates and more. The fourth article in the series features a dentist who is analyzing how to meet the patient demand of a high-volume PPO practice.
The California Medi-Cal Dental Program (Denti-Cal) is informing dentists across the state that it is OK to provide dental services to children on Medi-Cal, including foster children, if they come to their office without a BIC (Medi-Cal) card. In a notice recently sent out in the Denti-Cal Bulletin newsletter, the state's Department of Health Care Services clarifies that in accordance with the California Medi-Cal Dental Program Provider Handbook, no identification verification is required in certain circumstances.
The Dental Benefits Research Task Force recently heard the results of a CDA survey that delved into the patterns of dental consumers. The survey, conducted in May, gathered feedback from California adults. The Task Force, which is identifying strategies and recommendations to enhance the position of providers and patients in the dental benefits marketplace at the request of the 2011 House of Delegates, analyzed several key findings from the survey.
In a four-part series, CDA is profiling members who have taken different approaches to how they practice in order to counter changes in the profession such as an overall drop in adults seeking dental care, the decline in the economy and real estate market, increased regulatory compliance, reduced reimbursement rates and more. The second article in the series features two dentists who practice in San Francisco. In 2008, both dentists decided to end their participation as a contracted provider with dental plans. Five years have passed and both continue to operate on one fee schedule.
While California providers are still waiting to hear from Delta Dental of California about expected fee reductions for its Premier Plan, Missouri dentists received a letter recently from Delta Dental of Missouri that outlined plans in that state to reduce reimbursements to providers who participate in Delta’s Premier and PPO networks. The fee reduction, which went into effect July 1, averages 7 percent. Delta Dental of California has not been forthcoming with its reasons for cutting reimbursement rates, nor has it officially informed California providers about its intentions; however, the reductions are expected to be an average of 8 to 12 percent implemented later this year.
The California Dental Association applauds the governor’s signature of a new state budget plan that includes the restoration of Adult Denti-Cal services.
In a four-part series, CDA is profiling members who have taken different approaches to how they practice in order to counter changes in the profession such as an overall drop in adults seeking dental care, the decline in the economy and real estate market, increased regulatory compliance, reduced reimbursement rates and more. The first article in the series features a dentist who practices in Stockton with a diverse population, including low-income patients. During the last five to 10 years, she has made several changes in her practice to become more efficient.
The effort to restore Adult Denti-Cal benefits is one step closer to reality after the Legislature voted on a new state budget plan. The funding, which is a result of the leadership exhibited by Senate President Pro Tem Darrell Steinberg (D-Sacramento), still needs the governor’s signature. Steinberg made the restoration of Adult Denti-Cal a top priority after his visit last August to CDA Cares in Sacramento.
Legislation aimed at making sure dental plans put more of their revenues into actual care for patients passed its first legislative hurdle. AB 18, authored by Assemblyman Dr. Richard Pan (D-Sacramento) and sponsored by CDA, overcame strong objections from dental plans and health plans.
The move to restore adult Denti-Cal benefits is one step closer to reality after the governor and state lawmakers agreed to include funding in a preliminary budget deal. The restoration of benefits, which still needs final budget approval, would begin in May 2014, with a proposed annual cost of $77 million.
Two significant but conflicting developments in the longstanding effort to rebuild the oral health care safety net in California have occurred. In a disappointing move, on the same day that the state Senate Budget and Fiscal Review Committee endorsed restoring Medi-Cal adult dental benefits, the U.S. 9th Circuit Court of Appeals on May 24 denied a petition filed by CDA and a coalition of health care organizations aiming to stop the state from implementing a 10 percent reduction in Medi-Cal provider reimbursement rates.
CDA is sponsoring legislation to apply key patient protections and market reforms, including a minimum loss ratio on patient premiums, to dental plans participating in California’s new health plan marketplace, the Covered California health benefit exchange. The Affordable Care Act (ACA) includes many consumer-focused provisions that have already gone into effect, but that only apply to medical plans. Assemblymember Dr. Richard Pan (D-Sacramento), who chairs the Assembly Health Committee, has introduced AB 18, sponsored by CDA, that if passed by the legislature and signed by the Governor, would represent the first time these federal patient protections would be applied to dental plans participating in the small group market inside and outside the new health benefit exchange created by ACA.
As part of an effort to simplify providers’ participation in the state’s Medi-Cal Dental Benefits Program (Denti-Cal), CDA, with the cooperation of the State Department of Health Care Services’ Dental Services Department, has developed a guide to working within the program. The guide, entitled “Denti-Cal Provider Guide,” is divided into two main sections: Processing a Denti-Cal Patient Through the Dental Practice; and the Denti-Cal Billing Process.
Ann Milar, CDA dental benefits analyst, weighs in on why all dental offices must make sure they have the correct address on file with their contracted plans. This will ensure that the offices receive necessary credentialing paperwork, tax documents and other written communication from plans in a timely manner and avoid the potential of being unknowingly terminated as a participating provider.
The next wave of the Healthy Families Program transition to the Medi-Cal program is set to occur on April 1. It is important to note that the federal Centers for Medicare and Medicaid Services is requiring the state to again seek approval before they initiate this next phase (Phase 1c). There will be seven counties involved in the transition.
The CDA Dental Benefits Research Task Force has moved into the analysis and problem-solving phase of its efforts to identify strategies to enhance the position of providers and patients in the dental benefits marketplace. Walt Weber, DDS, chair of the task force, said there are a variety of things they are looking at and made it clear the group is ratcheting up its discussions.
The March 2013 issue of the CDA Update features ways CDA Presents is valuable for new dentists. Specifically, six courses that new dentists will benefit from are highlighted. Spotlighting the key role that sterilization volunteers play at CDA Cares clinics, Diane E. Morgan-Arns, who served as the lead for sterilization at the CDA Cares Modesto and Sacramento clinics, and Eve Cuny, director of Environmental Health and Safety at the UOP, Arthur A. Dugoni School of Dentistry are interviewed.
If the state gets the approval, Phase 1b of the Healthy Families Program transition will begin on March 1.
The CDA Dental Benefits Research Task Force heard from a dental economics expert with the ADA and learned about Oregon’s Coordinated Care Organizations at its January meeting.
California continues to move toward the Jan. 1, 2014, implementation of national health care reform, and CDA has been working closely with policymakers on issues important to dentistry.
The CDA Dental Benefits Research Task Force heard from group practice and network management experts at its December meeting. The task force, which is identifying strategies to enhance the position of providers and patients in the dental benefits marketplace at the request of the 2011 House of Delegates, heard from Gary Pickard, director of plan relations at Pacific Dental Services; Jeffrey Parker, CEO, and Burt Arthur, CFO of Sarrell Dental Center in Alabama; and Michael Grossman, DDS, former president and CEO of First Dental Health.
California is continuing to move forward with the transition of 875,000 children currently enrolled in the Healthy Families Program (HFP) to the Medi-Cal program, which is expected to begin on Jan. 1. For many months, advocates were pushing for the delay of the transition, but recently, many of those advocates have sensed the inevitability of the transition. The focus of many organizations has turned to ensuring the transition goes smoothly for families and on monitoring access to care as the transition occurs.
As part of its continued efforts to keep members up-to-date on the changing landscape of the dental benefits industry, CDA invited three experts in the field to speak to the 2012 House of Delegates last month.
The CDA Dental Benefits Task Force, which was approved at the 2011 CDA House of Delegates to develop a deeper understanding of the underlying pressures and trends in dental care financing, conducted several information gathering meetings this year. A summary of the task force’s work was presented to the 2012 House of Delegates on Nov. 10.
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