The Explorer Winter 2018 Explorer Winter 2018 | Page 13

CDA ADDRESSES QUESTIONS
ABOUT CHANGES IN PROVIDER
CONTRACTING
®
Reprinted with permission from California Dental Association
know any better. Some offices have
responded that perhaps they should
continue to bill associates’ care under
the single name of the owner.
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
Los Angeles Dental Society Explorer
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
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