Calling benefit plans for resolution or spinning your wheels?

This article is the latest in the semiregular “Dental Benefits 101” series launched in January 2017. Find additional installments in the CDA Update and on cda.org. 

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.

To illustrate, CDA Practice Support often receives calls from dental offices where the conversation goes something like this:

“We have a problem with Acme Dental Plan about ‘x.’ We spoke with Joseph in Acme’s customer service department. Joseph said that the problem can be resolved, but it has been a month and it hasn’t been resolved. We called Joseph again and he said it’s being worked on. More time passed and still nothing. We called Joseph again but he didn’t return our calls. Then we reached another person at the plan who said that the plan wasn’t likely to reverse its payment decision but that they would look into it.” And so on.

This office has reached the point where frequent calls to the plan have become fruitless, yet having received an early promise that “x” would be resolved, the office, hopeful, continues to call. The problem might eventually be resolved, but as the office’s efforts to reach or talk by phone with a plan representative have not been successful, it is more likely that the office will need to pursue a more formal path toward resolution.

Taking the formal path toward resolution

The provider dispute resolution process is a formal means of submitting grievances or appeals of disputed payment decisions to dental plans. First, a dentist must determine why the claim was denied. According to Health and Safety Code section 1399.55 and Insurance Code section 796.01, the plan must provide the dentist with a reason for denying a claim. This information is usually included on the plan’s explanation of benefits.

If the claim was denied, dental benefit plans have a formal process that allows providers to appeal when they do not agree with a payment decision, whether it’s disagreement with a claim denial, disagreement with a clinical (utilization management) decision or disagreement with the reimbursement. 

A clear understanding of the plan’s contractual obligations to cover a particular procedure is essential in a relationship between a dentist and a dental plan. Whether or not the dentist is contracted with the plan, he or she should review the plan’s utilization review guidelines, compensation methods, fee schedules and dispute resolution process. If a plan has violated any elements of its own policy, this would be the basis of an appeal. This information is typically made available through a plan’s payment policies or dentist handbook, which are usually found on the plan’s website.

The provider handbook provides information on requirements to submit claims properly, whether electronically or in working with clearinghouses. (The majority of claims are denied due to improperly filed claims or lack of correct information on a claim.) The handbook also provides a list of procedure codes with general processing guidelines. These are important to determine frequency limitations, exclusions, predetermination requirements and attachment guidelines that may apply to the procedures being claimed. The handbooks also may include a description of the formal provider dispute resolution process and either a form for filing a dispute or an address to which the dispute should be sent.

Plans are obligated to address formally filed disputes

While it might be desirable for dentists to resolve payment disputes with plans over the phone, plans have no obligation to resolve disputes through such an informal means.

However, plans are obligated to address disputes filed formally by providers. State regulations require all plans to have a provider dispute resolution process in place. State regulations also specify a process and, particularly, a timeframe within which a plan must formally respond to a formally filed dispute. Regulations allow providers to file a payment dispute within 365 days of the payment and plans are required to acknowledge receipt of a provider dispute within 15 days if filed by mail and two working days if the appeal is filed electronically. Also, plans are required to formally respond to the dispute within 45 working days.

There are no such requirements when dealing with a dispute informally, such as over the phone. An office might spend more than 45 working days trying to get to the right person to address a concern over the phone. In the time spent waiting to connect with a person by phone, the office might instead receive a formal response to a formally filed dispute.

When discussing provider disputes, CDA usually points out that rules pertaining to plans in California don’t apply to self-funded dental plans, as these are regulated by federal law.  However, self-funded plans are typically administered by dental plans doing business in California. So it’s not unusual for a commercial dental plan administering claims and payments for a self-funding group to use its provider dispute resolution process, required by state law, to consider providers’ appeals on self-funded group payments. While such a formal process is not required by federal rules, the formal dispute resolution process is a familiar and useful process for both plan administrators and providers.

In summary, we all would like to see a quick and easy way to resolve disputes with dental plans.  An initial phone call to a plan to broach an issue should not be discouraged, but phone calls may not result in a quick resolution or response. The formal provider dispute resolution process was established to, first, give providers a way to dispute unfair payment decisions, and secondly, to obligate plans to formally respond to providers’ appeals. The best way providers can avoid spinning their wheels attempting to reach a resolution with a plan is to file a formal appeal with the dental plan. It may require more work, but it will provide a definite response from the plan.

Find resources to assist with dental benefit plans in the Practice Support section of CDA’s website.

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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.