3 dental benefit trends you should know

Jun 6, 2024 by Mary Beth Versaci
ADA offers information, resources to help with concerns

Navigating benefits can be confusing and frustrating for dental practices, so the American Dental Association is sharing information and resources related to three new trends impacting dentists.

Some payers are raising the frequency limitation on fillings from two to five years. So far, Delta Dental of Colorado — for at least one employer group — and the Blue Cross Blue Shield FEP Dental program for federal employees have made this change.

“Frequency limits within the dental insurance landscape are something that dentistry has learned to navigate. Now, the landscape appears to be changing,” said Rod Hill, D.D.S., a former member of the ADA Council on Dental Benefit Programs. “While we as dentists have learned to accept the standard ‘warranty’ periods of 24 months for fillings and 60 months for crowns, we now must deal with the longer periods imposed by the insurance companies to decrease their liability.”

Some plans pass the fee on to patients, giving them the impression the restorations should last for the amount of time the insurance company deems appropriate, Dr. Hill said.

“For those plans that don’t pass the fee on to the patients, are we the dentists going to be required to ‘warranty’ these services due to contractual requirements?” he said. “If so, how do we justify the increase in the frequency limits without taking into consideration the individual patients’ habits, oral hygiene, and oral and systemic health, which can have drastic results on our restorative efforts?”

Patients often refer to the payment plan for their dental care as "insurance.” However, it's technically a different type of health care plan known as a benefit plan, which covers only certain costs. The ADA has created a brochure titled "Why Doesn't My Insurance Pay For This?" that explains this and other related matters to help patients better understand their dental benefit plans. This brochure is available for purchase through the ADA Store.

“In addition, dentists may want to voice their concerns regarding these policies with their provider relations managers at the insurance companies. After all, these plans should be held accountable for their actions,” said Sara Stuefen, D.D.S., chair of the ADA Council on Dental Benefit Programs’ Dental Benefit Information Subcommittee.

A second emerging trend relates to changes in how out-of-network claims are paid. Aetna has changed the way it determines these fees, leading to decreased reimbursements for dentists who are not in network.

As of Jan. 1, Aetna’s fees are based on the average amount insurers pay for services in a dentist’s geographic area as opposed to the average amount providers charge, as reported by Fair Health. Fair Health is a nonprofit with a database of more than 46 billion health care claim records that it uses to estimate average billing and allowed amounts across the country.

“This is particularly noticeable when an out-of-network patient receives preventive and diagnostic services. The patient is expecting the services to be covered at 100% with no out-of-pocket expenses; however, the services are covered at 100% of the plan’s allowed fees for out-of-network providers, likely leaving the patient with a balance due for these services,” Dr. Stuefen said. “For this reason, you may suggest that your patient file a complaint with their employer’s human resources department so that groups that purchase these plans have a better understanding of how their employees are affected by these policies.”

A third trend relates to network leasing. MetLife and Guardian will be leasing their networks to each other effective June 1. Both MetLife and Guardian providers can opt out of the leasing arrangement by following instructions provided to them in communications from the companies.

The ADA, working closely with state dental associations, has helped to pass PPO leasing legislation in 30  states. In addition, it has collaborated with the National Council of Insurance Legislators, which develops model legislation states can use to craft their own bills. NCOIL has adopted the Transparency in Dental Benefits Contracting Model Act, which aims to improve transparency throughout the dental insurance landscape. The act includes model legislation for network leasing, virtual credit cards and prior authorizations.

ADA members can receive assistance with insurance concerns by calling 1-800-621-8099 or emailing dentalbenefits@ada.org. The ADA’s contract negotation guide and in-office dental plan toolkit may also help dentists facing insurance issues.

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