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08/30/2013

Read dental plan mail closely to protect opt-in/out rights

By Ann Milar, CDA Dental Benefits Analyst

Dental plans send mail to providers for many reasons and it is important to have an office protocol for reviewing this correspondence to protect you from changes that you may later find affect your practice. This article provides one example of a dentist not being aware of an opt-out notice.

Dr. Z is contracted with ABC Dental Plan as a Preferred Provider Option (PPO) provider. Her office submits a claim on behalf of a patient and later receives the Explanation of Benefits (EOB) and check from ABC Dental Plan with the statement, “The network savings were obtained through a relationship with 321 Dental Network.” In addition to the EOB comment, she was paid less than her contracted rate with ABC Dental Plan.

Upon contacting ABC Dental Plan to investigate why the reimbursement was reduced, Dr. Z discovers that ABC Dental Plan utilizes the 321 Dental Network for some of its employer groups and that she is now a 321 Dental Network provider, even though she didn’t sign an agreement with 321 Dental Network. This scenario is becoming increasingly common throughout the country.

The dental benefits industry is very competitive and plans are constantly looking for ways to reduce its costs and increase market share. One way plans can achieve these goals is by leasing a provider network for its plans instead of going through the expense of building and maintaining a network on its own. This is why you may see Connection Dental, Maverest, Dentemax, Dental Health Alliance, Dental Health Partners, Stratose or others printed on some patients’ EOBs or dental plan identification cards. These are just some of the provider network entities that dental plans and third party administrators are leasing to expand provider networks instead of building their own network, provider by provider, state by state, region by region.

In this case, Dr. Z lost the ability to opt out of this expanded network because the dental plan notice was overlooked.  A CDA-sponsored law that went into effect  Jan. 1 this year requires dental plans to notify its providers 45 days in advance of any material changes to their agreements, rules and procedures. Dentists should read every notice that they receive from the plans in which they participate and note the date of the letter and the “reply by” date to ensure that the plans are conforming to the law and that the dentist replies appropriately within the required timeframe.

Reading the entire announcement is important as many times the language explaining the opt-out process for providers is buried a few paragraphs into the letters and is worded similarly to the following:

Your practice has the option of participating in the network; or opting out of participation. If you wish to participate in the network, you do not need to do anything further. To opt out of participation in the network, we must receive your written request by mail no later than …

For those dentists who are receiving EOBs or other information indicating they are part of a network that they do not recall signing an agreement with or receiving prior notification regarding their network participation, CDA staff recommends the following course of action:

  • Verify the network and plan affiliation by reviewing your participating agreements with dental benefit plans to confirm whether you are affiliated with the plan.
  • If you are a contracted provider for the plan but want to dispute or disenroll from the leased provider network, a sample letter (Declining to Be Included on Any List Conveyed to Payors That Do Not Actively Encourage Enrollee Use of Contracted Providers) can be found on the CDA Compass for adaptation and utilization.
  • If you are not a contracted provider for the plan or the leased network and wish to dispute the reduced reimbursement fees and network affiliation, contact the plan and notify them that you are not a contracted provider and request that the claims be re-processed as an out-of-network provider. If plan representatives state you are contracted with the plan, request a copy of the signed agreement validating your affiliation with the plan.

Looking ahead, it is strongly recommended that dentists establish an in-office protocol for reviewing their mail and dental plan correspondence (e.g., bulletins, credentialing forms, notifications) to ensure that plan communications are not overlooked. When verifying patient eligibility with a dental plan, also inquire about whether there is a particular network affiliation for the patient’s group. Finally, careful review of the EOB is encouraged to confirm dental plan benefit claims are paid correctly per your contract and network.

For additional information and resources on leased provider networks, visit the CDA Compass at cda.org/compass.