CDA's Involvement with Third-Party Payer Issues
CDA recognizes that dentist and patient issues related to dental plans are extremely important to our members. CDA staff is organized to respond to member inquiries on these issues on two levels: responding to members’ common questions and problems and through improving and shaping public policy.
Our Member Programs department, through their Resource Center, addresses third-party payer issues in an immediate way, when CDA members call with inquiries stemming from their day-to-day questions and problems regarding payer policies and practices. From these questions and problems, CDA is able to identify patterns of complaints about third-party payer practices. These patterns can then be reviewed for possible public policy implications, which is done within CDA’s Public Policy department. If it appears that a payer is following an egregious or inequitable business practice, Public Policy staff may be able to address the issue by bringing it to State Department of Managed Health Care, to obtain a clarification or initiate a regulatory response to the issue, or may be able to consider a legislative response, or refer the issue to CDA’s Legal Counsel for consideration of possible legal action.
CDA’s response to members’ calls on third-party payer issues typically involves a review of the contract between the payer and dentist to assure that the plan is not in violation of its own contract; a review of existing laws and regulations to determine whether a plan may be in violation of state requirements placed on dental plans; and informing dental offices of their right to appeal payment disputes and decisions made by dental plans.
CDA provides a variety of resources to assist members in responding to third-party payer issues:
- Each month, the CDA Update contains at least one article addressing a frequently asked question about third-party payer practices.
- Presentations for local component dental societies covering common payment concerns, suggestions for how to address these issues, and the rights of both patients and health care providers within managed care dental plans.
- CDA Online, which contains information on third-party payer issues.
- Scientific Sessions lectures on third-party payer issues of benefit to dental offices.
- CDA has developed a series of form letters with which dental offices may respond to specific third-party payer problems.
- In coordination with ADA, CDA can provide an analysis of a plan’s provider contract before a dentist signs onto a plan’s network.
CDA is also in the process of raising a number of issues with the State Departments of Managed Health Care and Insurance – specifically the issues down-coding and recoding of certain dental procedures; plan denials of payment after confirmation of eligibility; the failure of plans to promptly pay claims; refund demands on claims previously paid; lost claims and documentation received by plans; and coordination of benefits limitations.
To raise issues or ask questions about third-party payer policies and practices, call Kira Hough at 916.554.4969 in Member Programs. On public policy issues, contact Greg Alterton at 916.554.4994.