Necessary tools to evaluate dental plan provider agreements, establish and evaluate fee schedules and the impact to a dental practice.

No 'one size fits all' when it comes to dental benefit contracting
Adding or dropping a contract with a dental benefit plan is a personal business decision. There is no “one size fits all” in these types of business decisions, as what might work for one dentist might not work for another. You may be asking yourself how a dentist can make a good decision about adding or dropping a dental plan/network participation, but there is one key element in each success story.
Pause before you comply with a plan's request for post-payment chart review
Post-payment chart reviews are required by state regulators, such as the department of managed health care and the department of insurance. It is important to understand that the dentist has agreed to these types of reviews by signing their participating provider agreement with the dental plan. But, what happens when a dental plan requests a chart review or audit, but you are not a contracted, participating provider?
Billing dentists: Learn how to properly bill when another dentist performs treatment
Many dental benefit plans have adopted contracting based on the contract of the treating dentist, not just the billing (owner) dentist. When billing a benefit plan, the information documented on the claim in the billing dentist or billing entity, treating dentist and treatment location sections must all be accurate. If the treating dentist documented on the claim differs from the treating dentist noted in the patient’s chart, it’s considered to be fraudulent billing.
Is it a covered benefit? Understanding the noncovered services law
A common question received by Practice Support is whether a dental plan that a dentist is in contract with can dictate fees on procedures that the policy does not cover. What CDA members specifically want to know is what the dentist can charge the patient. I wish I could provide a simple answer, but the simple truth is that there is very little that is simple about the dental benefit marketplace.
Understanding audit authority of third-party payers
An often overlooked but very important component of contracting with a dental benefit plan is the plan’s authority to audit charts or records. State regulators require dental benefit plans to have quality management, utilization and antifraud policies and procedures in place to protect the insured. Performing these post-pay chart audits or reviews is one way plans comply with this requirement. They conduct these reviews to ensure that dental procedures reported by a dental office on behalf of an enrollee are consistent within the provisions of the dental benefits.
Dental benefit contracting: It’s not all about the fees
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.
Hang up and log in for dental plan benefit information
Benefit plans have started offering information through their own online portals. When these portals were first introduced, the information offered was insufficient at best and in most cases still required an office to call the plan with many unanswered questions. However, this is less the case today as many plans have worked to improve their portal functionality to better meet the needs of the dental community.
If I had a magic wand: Reflections on managing dental benefit issues
Greg Alterton is approaching his 16-year anniversary with CDA. He worked in the CDA Public Policy Division for 13 of those 16 years, where he was involved in developing dental benefits legislation sponsored by CDA. He has assisted individual members directly with their dental benefit issues while in Public Policy and during the past three years with CDA Practice Support. He retires from CDA at the end of 2017.
CDA addresses questions about changes in provider contracting
Have you ever had one of those moments when you received a decision from a dental benefit plan and thought, “There ought to be a law?” Well, there isn’t a law, in many cases. All health plans must meet requirements as determined by the state agencies that regulate, license and certify them. However, the issues that matter most to providers as well as patients — what is included in the plan’s scope of benefits, for example — are not governed by state laws or regulations.
Calling benefit plans for resolution or spinning your wheels?
There’s a reasonable assumption that calling a dental plan about a payment dispute will resolve the dispute. We’d all like to think this works more often than it actually does, but the reality is that informal calls to dental plans about payment or other issues the dental practice is having with a dental plan may not quickly lead to resolution.
Understanding dental plan audit authority
The new Congress and administration in Washington are negotiating legislation that would considerably dismantle the Affordable Care Act as one of their first objectives. While it remains to be seen what this repeal and replacement of the ACA will look like, one aspect of the ACA that will likely survive is the idea and objective of “affordable” health care.
Dental benefits 101: Proper billing, waiving co-payments
Beginning in the New Year, and with the forthcoming issue of the CDA Update, the dental benefits column will host a semiregular series discussing basic dental benefit issues. The topics covered address questions that CDA Practice Support receives from dental offices and from local dental components. This first installment addresses proper billing for treatment provided by an associate and waiving of co-payments.
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