California Insurance Commissioner Ricardo Lara last Wednesday issued a notice to California health insurance and specialized health insurance companies, including 55 dental benefits companies, requesting that they “provide their policyholders with a partial premium refund no later than December 31, 2020.
CDA Practice Support is receiving calls from dentists and their staff concerning claim denials for scaling and root planing services by dental benefit plans. In this article, I review the criteria utilized by dental plans when reviewing claims for scaling and root planing and why some of the plan denials are correct based on the American Dental Association’s definition of scaling and root planing.
Patients with some form of dental coverage or benefit to offset their out-of-pocket cost are more likely to accept a treatment plan. Offering an in-house discount plan can assist with attracting new patients and help retain existing patients, particularly those patients without any form of dental coverage.
With baby boomers exiting the workforce and losing their employer-sponsored dental coverage, consumers are enrolling in Medicare, the federally administered health care program for all seniors age 65 and older. Practice Support has seen an uptick in member calls related to Medicare Advantage dental plans due, in part, to the aging patient population in their practices and increased Medicare enrollment.
CDA-sponsored legislation that further increases dental plan transparency became law on Jan. 1. AB 954 requires dental plans to be more transparent about the leasing of dental networks. The new law will reduce patient and dentist confusion caused by the increasing number of plans leasing their networks to other payers, many times unbeknownst to the enrollee or contracted dentist(s). The law took effect for contracts entered into on or after Jan. 1, 2020.
Health care providers can expect to see major revisions to the Medi-Cal program over the next couple of years as a result of a new initiative by the Department of Health Care Services. Released in late October, the California Advancing and Innovating Medi-Cal (CalAIM) proposal will implement “broader delivery system, program and payment reform across the Medi-Cal Program,” according to the proposal summary.
CDA Practice Support receives hundreds of calls each year concerning the coordination of benefits when a patient has more than one dental plan for coverage. Standard COB allows secondary dental plans to pay up to 100% of the covered service, i.e., the primary plan pays the service at 80%, and the secondary could pick up the remaining 20%. Here, CDA’s dental benefits analyst covers the COB basics and answers common questions members have about COB.
Today, many dental benefit plans use auto-adjudication to process a high number of their claims. While auto-adjudication can speed up claim processing, if an office is not aware that this type of technology is being used, the office can be confused and frustrated by processing errors as the result of manual claims submission. The following three examples illustrate how a plan might use auto-adjudication and how that process might affect dental reimbursement.
Improvements to the Medi-Cal Dental program continue with new options for dentists who treat Medi-Cal members, including the ability to provide fluoride treatment and fluoride varnish as a benefit once every four months for patients under age 6. The increase in the benefit periodicity underscores the state’s commitment to regular preventive oral health visits for young children in California.