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.

Q: During your 16 years of experience working on dental benefit issues for CDA, is there one thing in particular that has surprised you?

A: One thing that’s interesting is how very few issues have changed. Every day there’s something new, and often quirky, but throughout my time at CDA I’ve heard pretty much the same issues involving coordination of benefits: what the primary and secondary carriers should pay; what dental benefit plans require for proper documentation with claims and, relatedly, why claims are denied; refund demands for overpayments; plans not updating dentist fees on a regular basis; recoding or down-coding of billed procedures; and appealing adverse payment decisions by a plan. There is also the issue of self-funded dental plans, which aren’t regulated by state law and typically require a different dispute resolution approach than do state-regulated dental plans. 

Surprisingly, these issues constantly reoccur. The office that understands why and how these issues occur and how best to respond to dental plans on these issues has the best chance of either avoiding these problems or seeking a revision of an adverse payment decision.

Q: What change in the area of dental benefits during your time with CDA was the most important to dentists?

A: Aside from the legislation CDA helped secure and in which I’m proud to have played a part, the biggest change for dentists in my view was the establishment of a formal process for all health care providers to appeal adverse payment decisions.

A formal provider dispute resolution process didn’t exist for dentists when I started at CDA. Helping dentists know and exercise their rights of appeal is probably the area where we’ve most frequently assisted members. We’ve developed resources for the CDA Practice Support section of cda.org describing the dispute resolution process and have written a number of articles in the CDA Update on this formal appeals process.

The provider appeals process has been part of every presentation I’ve given at local dental components and part of every lecture we’ve given over the years at CDA Presents, the biannual education convention. It’s usually part of every direct conversation we have with individual offices that call about a payment problem they’re experiencing. 

One of the requirements of the provider dispute resolution process is that dental plans are required to respond to formal appeals filed by dentists. If a dentist disagrees with the formal response of the plan, plans often give a second level of appeal or the dentist can file a grievance with either state agency that regulates health care benefit plans.

A right not exercised is a right that isn’t enjoyed or protected. The provider dispute resolution process is the best way to challenge and potentially reverse an adverse payment decision by a dental plan. CDA spends considerable time talking with dental offices or the dentists themselves on how to frame an appeal to a plan. Before this resolution process, there was no real formal way for dentists to appeal payment decisions they disagreed with, so it probably always will be something CDA educates our members on and assists them with.

Q:  If you could change anything in the dental benefits arena, what would it be?

A: It’s a big “if,” but if I could change one thing in the dental benefit industry, I would shift the mindset from thinking that dental benefits are “insurance.” Insurance covers calculated risks, e.g., what’s the risk that a male who is over 50 years old and smokes will get heart disease? Actuarial analysis calculates that risk among a certain group of people — potential policyholders — who meet those characteristics. Insurance companies manage that risk by charging a premium to address the level of risk within a population and does so in a way that covers those at risk and guarantees the insurance company doesn’t go bankrupt. 

Dental benefit plans are different. Dental plans do not have the same high-dollar risk implications of a medical plan. No one is likely to lose their house due to the cost of dental care, but a week’s stay in a hospital may bankrupt some. Revisiting my example, due to the eventual cost of care, providing medical insurance to a 50-year-old male who smokes and develops heart disease is significantly riskier than the risk for a dental plan providing a benefit for the same patient. Consequently, dental benefits are not “insurance,” per se. Dental coverage is more of a payment assistance program for enrollees. In my opinion, that’s the way consumers and the dental plans should view it: as a means of paying a portion for dental care, not as a way of eliminating all financial risk for that care.

Q:  Do you have any regrets during your time at CDA?

A: My biggest regret is that I didn’t have a magic wand to fix our members’ dental benefit problems. During my professional life, I’ve worked in a good number of settings – with the Legislature, for the governor’s office, for the state Chamber of Commerce, for professional associations, in private industry in a couple of Fortune 500 companies and for regional government. I’ve worked on issues related to environmental quality, criminal justice, business and health care. In all of the positions and of all the organizations I’ve worked for, I’ve never been among a more intelligent, dedicated, professional and creative group of people than those I’ve worked with at CDA. The challenges of helping our members, particularly in the area of dental benefits, are huge, and I wish we could easily resolve every problem that comes our way.

I know members hear this all the time, but as someone who has spent the past 16 years on the inside, I can say that today and going forward CDA members’ concerns are in the best of hands. I’m glad for the opportunities I’ve had at CDA and have enjoyed working with CDA’s volunteer leaders. I am proud to have worked with the people I’ve worked with. They’re the best people anywhere.

Find more CDA Practice Support dental benefit resources online.

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