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When it comes to dental benefits, ask CDA Practice Support before you act

June 13, 2019 2307
Dental Benefit Plans

There is an old saying: “An ounce of prevention is worth a pound of cure.” I believe this statement can be applied to any area, including business decisions.

As the dental benefits analyst for CDA Practice Support, one of my responsibilities is to write this monthly column about the dental benefit marketplace. Many of my topic ideas stem from call trends or patterns. When I see an uptick in calls related to a specific dental benefit topic, I’ll write an article to share important information with member dentists who may not be utilizing their member benefit and calling in for practice support.

The following are the top 10 “post-op” calls, so to speak, that CDA Practice Support has received from dentists who “made a decision,” whether through action or inaction, that resulted in an unexpected outcome and ended with a member saying, “I wish I would have called Practice Support before I …” I’ve included titles of past Update articles that specifically address questions raised in these calls so members can find even more details, if needed. Find them at

  1. I purchased a practice and assumed that the contracts and compensation the selling dentist had with the dental benefit plans would transfer to me as the new owner.

    When purchasing a practice, the seller’s agreement and fees may not transfer to the new owner. The purchasing dentist should contact the plans to get a copy of the fee schedule and agreement they will sign if they buy the practice before they make an offer. Learn more in the April 2018 Update article “Dental benefit contracting: It’s not all about the fees — What you need to know before you sign.”
  2. During the sale of my practice, I was told it was OK to allow the purchasing dentist to use my Tax Identification Number to bill the dental benefit plans while they were in the process of contracting with the plans. I’m finding out there is more to this billing practice than I first assumed.

    Read about the risks involved in the above-described billing practice in the January 2019 Update article “Improper billing during practice transitions is risky business.”
  3. I signed a dental plan contract and all of a sudden they changed the contract language and/or the contracted fee. This can’t be legal, right? 

    Plans legally can and do make changes to their contract, and sometimes these changes affect the contracted fees. That is why it’s important to read all correspondence from dental plans. Learn more in the February 2018 Update article “Dental plan correspondence — it’s not all junk mail.”
  4. I received a re-credentialing notice from a plan. I missed the deadline to comply by only one day. I assumed it would not be an issue, but the plan notified me that it has terminated my contract. They are also saying if I want to contract with them again I have to sign a new contract and accept lower fees. Can they do this?

    Learn more on re-credentialing and the consequences of not complying in a timely manner in the February 2018 Update article “Dental plan correspondence — it’s not all junk mail.”
  5. I received a letter from a plan telling me they will be conducting an audit of my patient chart records. They want me to send them 25 charts for patients covered by them. Must I comply with this request?

    Learn more about dental plans’ authority to audit in the May 2018 Update article “Understanding audit authority of third-party payers.”
  6. I complied with a dental plan’s requests to send them 25 charts for patients covered under this plan. Now the plan is asking for a large amount of money back. I’m not in contract with this plan, so do they legally have the right to audit my charts?

    Dentists should be aware that while a plan with which they do not have a contract cannot require participation in an audit, dentists who voluntarily submit to an audit are likely obligated to open their patients’ records to be reviewed by the plan. Learn more in the February 2017 Update article “Understanding dental plan audit authority.”
  7. I called a dental plan for a breakdown of benefits and they misquoted the policy and its limitations, which resulted in a denied service and an unexpected bill for the patient. Both our patient and office have filed a complaint with the plan, but they are saying that information provided over the phone is not a guarantee. 

    To minimize misquotes and to obtain more detailed policy information, including limitations and exclusions, I recommend using a plan’s online portal. Many plans today have online portals that house patients’ eligibility, benefits, treatment history, frequencies, remaining maximums, deductibles, exclusions and limitations. Learn how to use these online portals in the January 2018 Update article “Hang up and log in — dental plan benefit information is a click away.”
  8. I spent months on the phone trying to get a claim reprocessed. Now the plan says I have surpassed the timely filing limit. Isn’t there a state law that says I have 12 months to submit a claim?

    There is no law in California concerning timely filing. Dental benefit policies can and do have different filing time frames, including very short time frames, which is why it’s important to know what the policy states. Rather than waste your time calling the plans trying to get a claim reprocessed, initiate your right under state law and file a formal written provider dispute with the plan. Learn more about this important right in the July 2018 Update article “Provider dispute process offers fair, fast and cost-effective resolution.”
  9. I am a contracted dentist with a plan and I assumed the contract would follow me to my new practice location. I called the plan to let them know about the new location, but they said that is not an option and instead are requiring me to sign a new contract for the new location, and the compensation is not the same as my current location. Is this legal?

    Not all dental benefit plan contracts are portable; in fact, many are location-specific. When adding a location, find out if the dental benefit plan contracts are portable. Additionally, find out if the contract and compensation will differ at the new location before you make the decision to open a new location. For more information, read the April 2018 Update article “Dental benefit contracting: It’s not all about the fees — What you need to know before you sign.”
  10.  A dental benefit plan I’m in contract with performed a chart audit a few months ago. I received a report from them and they are asking for monies back. They say they are demanding a refund because I did not have in-depth documentation of the treatment provided in the patient’s chart record. Is this legal?

    Dental benefit plan quality-assurance consultants are trained to look for patterns. One pattern they look for during a review is the lack of documentation. When no record can be found to prove that a claimed service was provided, plans often will say the service was not provided and demand the funds paid for the service to be returned. Learn more in the June 2018 Update article “When refund demands follow audits by third-party payers.”

If you have questions about dental benefits, contact the CDA Practice Support experts before you act. Call 800.232.7645 or submit your question online.

This column was authored by Cindy Hartwell, dental benefits analyst at CDA Practice Support.

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