09/11/2017

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, what limitations and exclusions apply to coverage, how much plans pay for treatment and how often they adjust their fees, for example — are not governed by state laws or regulations. They are the responsibility of the plans. Patients and providers must be diligent about knowing and working with these policies and making appeals based on the policies, as contracts between dentists and plans govern most of the issues dentists will experience.

CDA continues to receive questions from members about recent changes in how plans contract with dentists. These changes affect how plans pay and how practice associates are included in plan networks. To address these questions, here is an overview of the significant changes seen in provider-plan contracting over the past few years.

Payment

Dental plans have increasingly moved toward payment of claims based on who rendered care. It wasn’t that long ago that dental plans almost universally paid claims based on the contract status of the practice owner. The practice could have associate dentists treating patients but the plans would pay based on the contract with the practice owner. No more. Now the standard ADA claim form has places for the billing provider (the owner, in whose name a reimbursement check for the claim will be paid) and for the renderer or treating provider. Plans have moved toward payment based on who rendered care and what that associate’s contract status is with the plan.

For most plans, this makes little to no difference in how claims are paid. But when there is a difference in how the owner of a practice is contracted and how the associates are contracted with the same plan, it does make a difference.

Differences in contract status between the owner and the associate are the main reason payments are increasingly being made based on who rendered care. We first started seeing this change some five years ago, but some dental offices still call to ask how plans pay vis-à-vis the contract status of the associate. Some offices say they prepare claims in the name of the owner as they’ve done for a very long time. They do this out of habit (because “that’s the way it’s always been done”) and because they don’t know any better. Some offices have responded that perhaps they should continue to bill associates’ care under the single name of the owner.

If there’s a difference in how the owner is paid versus how an associate is paid, the desire to bill under the owner is understandable. But CDA’s response is as follows:

  1. Now that they know this an improper way to bill for most plans, they have an obligation to do it the correct way.
  2. If an office continues to file claims in the name of the owner for the purpose of avoiding a different fee schedule assigned to the associate, an office will get away with that until they are audited by the plan, and plans have become more aggressive in auditing the dentists they’re contracted with.

Contracting associates

Increasingly, plans want all dentists associated (and this is key – dentists who are associates of the practice are employed by the practice) to be separately contracted with their plans. As discussed above, some plans have different fee schedules for treatment based on when or how recently a dentist contracted with the plan. For this reason alone, plans want each dentist associated with a practice to have their own contracts with the plan.

Aside from a possible differentiation of fees, plans also look to credential contracted providers to assure they are up to date on their licensing requirements (e.g., have required continuing education credits), have liability insurance coverage, aren’t practicing under a suspended license and are not on probation. And associate contracting assures the plan’s ability to audit treatment and billing done for the associate.

Because of these requirements to contract with practice associates, some practice owners have considered bringing independent-contractor dentists into the practice. These are dentists who bring their own practices under the roof of the dental practice. They bring their own plan contracts, they tend to be specialists who bring their specialty expertise into general dental practices, and they submit their own claims.

Contracting new practice owners

It is a myth that when a dentist purchases a practice from another dentist, the new owner to some extent inherits the contract status of the previous owner. This is not the case with any plan in California. A previously noncontracted provider who purchases a practice — and this could be a dentist moving into the area and purchasing an existing practice or an associate with a practice who steps up to buy the practice of a retiring dentist — will need to establish their own contract with whatever plans they desire to do business with.

However, this isn’t the case with every dental plan. Some dental plans allow for “portability” of a dentist’s existing contract. If a dentist has been contracted with some plans, either as an associate in the practice they are buying or contracted in another location in California, that contract status will follow the dentist to their new location and be applied in the new ownership status. Of course, any plan would need to know about a change in status or of address in regard to practice ownership. But, again, not every plan allows this portability. Be aware that a dentist purchasing a dental practice may have to recontract when becoming the new owner of a practice, and this could mean a change in how the dentist, as the new owner, is paid by the plan.

Similarly, if a dentist has been the sole proprietor of a practice and decides to incorporate or bring a partner into the practice, this change in ownership structure may result in having to recontract with some plans.

Contracting at a new location

As mentioned above, taking over a practice as a new owner may likely require recontracting with one or more dental plans. But with some plans, provider contracts are portable, meaning a dentist may take their contract wherever they practice in California, either as an associate or as the owner of a new practice.

Changing practice locations doesn’t precipitate a new contract with plans. That would constitute a simple change of address. But there may be a requirement to establish a new contract if a practice opens a second location. The existing contract a dentist has with plans will apply at the original location, but a new contract may be required at a new second location. Again, most plans won’t require a new contract for this location.

In summary, the need to adjust to marketplace realities has prompted some dental plans to change the way they contract with dentists. The key takeaways: 1) Hiring associates requires establishing plan contracts for those associates; 2) Payment of claims is mainly based on who rendered the care being claimed; 3) Purchasing a practice may result in recontracting with plans. A dentist who already has a plan contract may be able to bring their existing contract status into that newly purchased practice, but the contract status of the former owner can’t be transferred to the new owner. And while a change in location usually doesn’t require the dentist to recontract with plans, opening a second office may.

In any of these situations — hiring of an associate, changing locations or purchasing a practice — it would be best to contact CDA Practice Support to discuss the usual contracting requirements.

To discuss contracting requirements, contact CDA Practice Support at 800.232.7645.



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