This article was authored by Dental Benefits Analyst Cindy Hartwell.
I’ve heard from some dentists who signed on to a plan’s network only to discover afterward that the plan has certain policies and procedures that the dentist disagrees with. It appears, then, that the advice “buyer beware” also applies to one considering “buying” into a provider network.
Many of the complaints CDA Practice Support hears from dentists are about plan payment policies that are often spelled out in the provider contract or handbook, so a thorough review of a plan’s provider contract prior to signing is strongly recommended. While dental benefit plans are doing business in the same marketplace, that does not mean they all do business the same way.
In calls to Practice Support, dentists often question the legality of a plan's decisions or processing policies. The first question we respond with is “Are you in contract with the plan?” A contract is a voluntary arrangement between two or more parties that is enforceable by law as a legal binding agreement. A plan’s contract binds the dentist to follow that plan’s policies and procedures, which can change the way a dentist is accustomed to doing dentistry.
Analyzing and reviewing a contract prior to signing it can save you considerable time and frustration. Because a contract is not just about fees, here are things to consider and ask yourself when reviewing one:
- When you sign the contract with the plan, will you be in network with just one network or multiple networks?
- Ask about each network’s size and the compensation for each network.
- Does the plan participate in network leasing and/or selling?
Often you will find that the higher the fee schedule, the smaller the network and vice versa: the larger the network, the lower the compensation. Ask how many of the plan’s groups are self-funded. Self-funded groups (e.g., employers that pay for their own claims) often will hire a plan to administer their benefits for them to keep costs down and to relieve administrative burden. Self-funded groups are federally regulated and, for that reason, many California fair business/practice laws do not apply to these groups.
As an in-network provider, you are obligated to follow the plan’s processing guidelines. It’s important that you read not only the plan’s contract but also its handbook, which typically explains benefits, limitations, bundling, downgrading and information on plan audits and recoupments. Be sure to ask for the plan’s handbook. In addition:
- Ask for the plan’s participation rules and regulations.
- Ask about the length of the agreement, e.g., three months, one year, etc.
- Check with the plan’s state regulator for complaint history.
Health care service plans must receive a license from the Department of Managed Health Care in order to operate in the state of California. Visit the department’s website to access the Health Plan Dashboard, which lets you view and compare plans and review the plan’s enrollment, complaint and enforcement actions history.
Weigh the costs before you sign a contract. A good question to ask yourself is: Will contracting and then terminating from a plan damage my practice more than if I had never contracted? In other words, will my patients’ in-network versus out-of-network benefits change? Here’s an example: If in-network preventive is paid at 100 percent of a contracted discounted rate while out-of-network preventive is paid at 80 percent of the plan’s maximum allowance, your patient would then have a co-payment for services that he or she was accustomed to receiving free of charge.
When purchasing a practice, the seller’s agreement and fees may not transfer to the new owner.
- Contact plans and get a copy of the fee schedule and agreement you will sign if you buy the practice before you make an offer.
When selling a practice:
- Inform the plan of the sale, as many agreements require you to do so within a certain time frame. Be sure to tell the plans about any transitional treatment and completion time frames to avoid premature contract termination that could influence claims processing.
When adding a location:
- If you are under agreement at your current location, find out if the agreement is portable and if the agreement and compensation will differ at the new location.
When contracting an associate:
- Do not assume the agreement and compensation of the contracted billing provider will be the agreement and compensation of the associate. The agreement and reimbursement rates may have changed since the billing provider was originally contracted.
When merging practices, some plans will require that a new contract be signed, which could result in different network participation and compensation.
- Contact the plans for their policies on merging a practice.
Some plans can take up to 90 days to process an agreement, so if you do decide to contract with a plan, find out from the plan the typical application processing time frame. In the meantime:
- Ask the plan if it will allow assignment of benefits to an out-of-network or potential provider. If the answer is no, it means the patient, not the provider, receives direct payment for the services provided.
Take advantage of your tripartite membership benefits and utilize the ADA’s contract analysis, which is available by contacting CDA Practice Support. Additionally, CDA Practice Support has resources to help you when considering contracting with plans:
If you are confused, seek legal guidance from an attorney familiar with dental plan contracting and practice mergers. But in the end, if the policies and practices of a plan do not meet with your expectations or if participation in the plan does not make sense for your practice as a business arrangement, it might be best not to sign the contract.
CDA Practice Support analysts can assist you in the areas of dental benefit plans, practice management, employment law and regulatory compliance.