Provider dispute process offers fair, fast and cost-effective resolution

How many times have you called a benefit plan to try to dispute a decision and been told by the representative that the plan would review and resolve the  issue shortly? But a few weeks go by with no communication from the plan, so you call again to check the status and are told that the plan has no record of your first inquiry. The representative makes another promise and gives you another date for resolution but that date also passes. You call the plan for the third time and get more promises but still no resolution, and so the cycle repeats.

Here is when members usually call CDA Practice Support requesting help. I typically begin by asking callers if they filed a provider dispute with the plan. If the answer is yes, I ask a few clarifying questions, including whether the request for reconsideration was sent to the plan in writing. For those who answer yes, I ask if the correspondence clearly stated that the provider initiated the dispute mechanism, as it is the provider’s right to do so under California law. We must ask these questions because there is a big difference between informal and formal disputes.

Informal versus formal appeal process

In an informal appeal process, a provider who disagrees with the plan’s decision sends additional clinical evidence to support the need for the treatment provided and denied by the plan. Sometimes this works and the issue is resolved. Other times the issue remains unresolved.
However, Health and Safety Code section 1399.55 and Insurance Code section 796.01 require that plans have in place a provider dispute resolution mechanism that is “fast, fair and cost-effective.” This is what we call a formal appeal process, and while this process is a powerful and effective right of a California dentist, it is also one of the most underutilized rights.

Simply asking a plan to reconsider a decision does not initiate the provider dispute mechanism. A request made by phone call or email or otherwise not made according to the plan’s established procedure will be treated as an informal appeal, which should be used only once. If it does not result in resolution, the dentist should file an appeal through the provider dispute resolution process established by the dental plan. Doing so will ensure that the issue is formally, fairly and efficiently addressed.

State law requires health plans to acknowledge receipt of a formal appeal within 15 days of receipt and to resolve the appeal within 45 working days. Additionally, state law requires plans to report the number of provider disputes filed with the plan in an annual report to their regulatory agency; with the informal process, however, state regulators are not alerted to a potential violation of law by a plan. If the formal appeal is not resolved to the satisfaction of the dentist, he or she has the right to take the appeal to the plan’s state regulatory agency. On the other hand, with the informal process, there is no mandate to respond within a specific period. Furthermore, the provider cannot file an appeal with the regulator without first formally filing a dispute with the plan.

Role of the DMHC

All health care service plans are required to receive a license from the Department of Managed Health Care in order to operate in the state of California. The DMHC’s website provides information for consumers and employers who want to view or compare health plan information. The health plan dashboard features health plan contact information, enrollment data, complaint and enforcement actions and financial data.

The DMHC website states that it works aggressively to monitor and take timely action against plans that violate the law, looks for unfair payment patterns and will perform emerging trend analysis on all provider complaints. Trending data will support the routine and nonroutine financial examinations performed by the department’s Office of Financial Review.

We all know what happens in many households when a child brings home a bad report card: action is taken and, in most cases, the child corrects their behavior. The health plan dashboard acts like a plan’s report card to their regulator. Unfortunately, if issues go unreported to regulators, a plan that is performing poorly can receive a false positive report. Of course, if the regulator thinks the plan is performing well, the regulator will take no action and it is highly unlikely the plan will change its poor behavior.

Your patients are also impacted if a plan is not accurately processing claims. Get your patients involved; they have the right to appeal to both their plan and their plan’s regulator. In fact, the DMHC states that in 2016 more than 69 percent of enrollees who submitted an Independent Medical Review complaint received the service or treatment they requested. If the plan does not satisfactorily respond to an appeal, the complaint can be forwarded to the plan’s regulator. The Department of Insurance and Department of Managed Health Care both have online complaint forms on their websites (DMHC’s complaint form).

For more information on this or other dental benefit issues, contact CDA Practice Support at 800.232.7645.

This column was authored by Cindy Hartwell, dental benefits analyst at CDA Practice Support.

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