Top 5 dental benefit issues -- and what to do about them

SAN FRANCISCO - Chances are your dental school didn't cover dental benefits, but they're still an important part of running a practice. Staff from the ADA Practice Institute discussed common dental benefit issues and how to solve them at this week's 2019 joint ADA and FDI World Dental Federation meeting.

Dave Preble, DDS, JD.

Dave Preble, DDS, JD, vice president of the ADA Practice Institute, spoke to DrBicuspid.com about some of the problems dentists encounter when working with dental payors. One of the most common misconceptions is that dental benefits work like medical insurance.

"Many dental offices believe dental plans to be true insurance, similar to medical plans," Dr. Preble said. "Unfortunately, dental plans are defined benefit plans with low annual maximums, with no insurable catastrophic risk, and they do not provide coverage for all dental procedures."

The ADA Practice Institute's Center for Dental Benefits, Coding and Quality has received thousands of problems and concerns from dentists about dental benefits and the Code on Dental Procedures and Nomenclature (CDT Code). Below are the top five benefit issues the center encounters:

1. Claim denials
2. Coordination of benefits
3. Explanation of benefits statements that interfere with the dentist-patient relationship
4. Payor's processing policies
5. Contract clauses

Dr. Preble noted these issues have something in common: They reduce the benefit to the patient.

"The benefit plans try to justify this by saying they are protecting the patient from unscrupulous dentists," he said. "But with improper billing, by the plan's own estimates, being less than 5% of claims filed, this really keeps money from going to the care patients need and for which they have paid premiums."

As a result, a patient's dental benefits may not cover treatments that a dentist believes to be essential. If a treatment isn't noted in a contract, it may not be covered.

"Just because a patient needs a certain treatment does not mean the plan will pay for that treatment," he said. "What is covered is defined by a contract, not by what the patient needs."

To help make the most of dental benefits, Dr. Preble offered dentists a few tips. First, dentists should read contracts carefully and consult with an attorney before signing a managed care agreement. In addition, it's important to review the payor's dentist manual and national processing policies before seeing in-network patients.

Finally, the ADA has multiple resources for members, including the ADA Third Party Payer Concierge, the ADA Credentialing Service, a contract analysis service, and even archived dental benefits webinars.

"ADA staff helped over 7,000 member dentists through calls and email inquiries on the CDT Code and third-party issues in 2018," Dr. Preble said. "Dental offices are encouraged to contact the ADA for assistance."