How dentists can handle the provider grievance process

By Ann Milar, CDA Dental Benefits Analyst

CDA receives thousands of member calls each year on the four major topic areas of a dental practice: dental benefits, employment, practice management and regulatory compliance. Dental benefits receives more than 3,000 calls per year, and of those calls, I approximate that about half of them are related to a dental plan not doing what the dentist (and their staff) expected.  

Many times when a dental plan has mishandled a claim or appeal, CDA recommends dentists utilize the provider grievance process afforded them through state law and their participating provider agreement with contracted dental plans. The provider grievance (also referred to as a dispute) is a tool that many dentists fail to utilize due to the time or effort required to do so.

Yes, writing a dispute or filing a grievance does involve some time, how much or how little is contingent on the circumstance. Depending on the issue, reporting a problem with a dental plan may or may not impact your individual case, but it could help you and the profession in the long run.

Regulators hold dental plans accountable for tracking provider grievances, including acknowledging the receipt of and responding to the grievance within 45 business days. Plans are required to report enrollee and provider grievances to their regulators (in California it’s usually the Department of Managed Health Care, also known as DMHC, or the Department of Insurance). When a provider’s issue isn’t resolved by the plan, providers have the right to file a complaint with the regulator about the plan’s handling (or mishandling) of the issue. Those complaints are also tracked by the department, and when the department sees a trend occurring within a plan, the agency may take a closer look at the issues reported by providers in a scheduled, routine survey of the plan or in a non-routine survey.

Routine dental surveys are conducted every three years of Knox-Keene licensed plans by the Department of Managed Health Care, and these usually include a review of the dental plans’ access and availability of care for its enrollees, utilization management, quality assurance/management program, the process for handling grievances and appeals, and plan compliance with language assistance. Non-routine surveys are conducted by the department according to Title 28, California Code of Regulations section 1300.82.1(a)(2), which allows the department to conduct a Non-Routine Survey for good cause under Section 1382(b) when the director has reason to believe the plan has violated Section 1370 of the Health and Safety Code.

A recent example of non-routine dental surveys includes the 2012-2013 review of the four dental plans (Access Dental, Health Net, Liberty Dental and Western Dental), licensed by the Department of Managed Health Care, that are contracted with the Department of Health Care Services for the provision of dental services through the Sacramento Geographic Managed Care Program to children enrolled in the Denti-Cal program. This non-routine survey was prompted by media and the Legislature amid reports that children were not obtaining services in a timely manner and were not receiving the appropriate level and quality of care for their dental needs.

Delta Dental of California was the subject of a more recent non-routine survey conducted by the Department of Managed Health Care. This examination was conducted for cause based on complaints received by the department from plan providers regarding claim processing. Details of the examination findings are available on the DMHC website, but in short, the department found that Delta was engaging in “unfair payment patterns” by failing to reimburse at least 95 percent of complete claims with the correct payment, including the automatic payment of all interest and penalties due and owing over the course of any three-month period. Additionally, the department found that Delta failed to comply with the requirement to provide a fast, fair and cost-effective dispute resolution mechanism for providers. While DMHC found that Delta’s compliance efforts are responsive to the deficiencies cited and corrective action plans are required, some of the violations will be referred to the Office of Enforcement for possible administrative action.

I share this information with the hope of reassuring those who take the time and energy to submit a grievance or dispute with a plan or the department that their time is not wasted. Accurately reporting a concern with a plan regarding payment, the grievance process, the quality assurance program, etc., is reviewed by the agency and considered as they evaluate overall dental plan compliance and performance. From the department’s viewpoint, if the plan isn’t working effectively with its providers, there is a trickle-down effect to the plan enrollees — your patients. And it’s your patients that you and the regulators ultimately serve.

This is not an appeal to inundate the plans or the regulators with provider complaints, but a reminder that your concerns matter – they matter to CDA, to the dental plans and to the regulators of the plans. Problems cannot be solved if they aren’t identified and noted, so taking a moment to document the issue and submit it to the proper entity is of great value and can improve a situation in the long run.