Dental Benefits and Reimbursements

By Srini Varadarajan, J.D.

According to the American Dental Association’s (ADA) Health Policy Institute’s (HPI) 2020 Annual Dental Industry Report, private dental insurance reimbursements continue to trend downward; between 2013 and 2017, HPI noted a 6% decrease in dental reimbursement rates across dental practices, procedures and carriers.

Dental specialists have especially felt the pinch. In California, a large carrier had provided notice of intent to reduce scheduled fees for endodontists, periodontists, and oral surgeons, but has since indefinitely postponed these reductions. While the decision was entirely that of the carrier based on its own determinations, the California Association of Oral and Maxillofacial Surgeons, the California Society of Periodontists, the California State Association of Endodontists, and the American Association of Endodontists (AAE) appreciated the opportunity to share with the carrier and the California Dental Association the concerns of specialists with regard to how proposed fee cuts would have substantially limited their abilities to practice, especially during COVID-19. However, carriers in various states  continue to explore and engage in various fee cuts affecting the specialty of endodontics.

So what can endodontists do? Before this question can be answered, it is important to understand what endodontists must not do. With few exceptions, federal antitrust laws prohibit endodontists and other professionals from engaging in coordinated or concerted action to set prices or limit the ability of insurance carriers to compete. The mere perception of such behaviors can invoke legal concerns. For a more comprehensive understanding of federal antitrust laws, please review the ADA’s The Antitrust Laws in Dentistry: A Primer of “Do’s, Don’ts and How Tos” for Dentists and Dental Societies.

Some AAE members have inquired as to how endodontists and insurance carriers appear to have to play by different rules, where insurance carriers appear to drive down reimbursements and engage in other actions that limit the ability of endodontists to succeed. While the McCarran-Ferguson Act of 1945 provided insurance carriers an exemption from federal antitrust laws by giving states a nearly unfettered authority to regulate the business of insurance, the Competitive Health Insurance Act of 2020 overturned that exemption. This effort was led by the ADA, but the AAE is pleased to have joined the ADA and other organizations through representation on the ADA’s Political Action Committee (ADPAC) and the Organized Dentistry Coalition (ODC), and engaged in its own actions, including over 1,000 letters delivered from AAE members to legislators, to help in overturning the McCarran-Ferguson exemptions. However, with limited definitions of the “business of insurance” and the uncertainty of the extent to which federal agencies will execute its authority, time will tell as to the effect of the new legislation. The AAE will continue to advocate on your behalf by exploring opportunities to encourage enforcement, and requests members to contact the AAE with any information about activities of insurers that may violate federal antitrust laws.

In the meantime, what can endodontists do to improve reimbursements?

First, read your PPO contract, and understand its provisions. Your PPO contract will outline notice requirements for contract and fee revisions. Additionally, your contract might have clauses addressing whether the insurer can lease your network and what fees may apply in the event your network is leased, whether the payer can seek a repayment of an alleged overpayment, and more. The AAE cannot provide you with legal advice about your contract as that requires an attorney licensed in your state, nor can the AAE advise you on whether to participate in an insurance company. However, the AAE would be pleased to review your contract and explain its terms. Please send your contract to advocacy@aae.org to request review.

Second, when submitting claims, make sure you submit your own usual fee, not the fee schedule fee. Insurance carriers periodically review claimed fees to determine adjustments to their fee schedules; so, if practitioners enter the fee schedule fees on their claims, it drives a further reduction in future reimbursements and fee schedules, and essentially creating a vicious circle of fee reductions over time.

Third, consider evaluating your own practice’s fees each year and updating your fees as appropriate, for example, to reflect the increased costs of materials, technology, and other overhead. While large increases in fees may affect patient retention, many patients may understand and appreciate the need for small adjustments to reflect changes in cost of practice. While the AAE cannot advise endodontists on fees to establish, resources such as FAIR Health (www.fairhealthconsumer.org)  provide patients and practitioners with data on in-network and out-of-network fees for various procedures by zip code; unfortunately, FAIR Health does not provide data by specialty.

Fourth, if your patient is concerned about a balance bill or a procedure that is not covered, you may suggest that he or she speak with his or her employer. As purchasers of dental benefits coverage for their employees, employers may be unaware of the effects of both coverage limitations and limitations to annual maximums that enable them to buy cheaper insurance.

Fifth, consider negotiating your fees. Federal antitrust laws prevent the American Association of Endodontists (AAE) from directly negotiating fees on behalf of their members. However, practice management and fee negotiation and optimization businesses can offer your practice these services. The willingness of carriers to negotiate fees may depend in part on whether their networks have enough endodontists and other dentists in your area to retain and attract subscribers.

Lastly, if you have any questions about an insurance matter, please contact the AAE at advocacy@aae.org. Unfortunately, insurance carriers have significant leverage and autonomy over many of their business decisions such that the ability of the AAE and other dental associations to influence these decisions can be limited at times; moreover, available actions can be limited by your contractual obligations with the carrier.

However, the AAE continues to expand its role in advocacy to try to help endodontic practices be more successful. The AAE has ramped up its coding advocacy, and, through its coding experts, has successfully revised the CDT the last two years to address gaps in the CDT for endodontic procedures; while carriers are not required to cover every code, existence of a code is a prerequisite to enable coverage for that specific procedure. The AAE Endodontists Guide to CDT is updated each year to reflect changes to the CDT; the Guide also provides a brief summary of common ICD-10 diagnostic codes that might be included in submission of claims for insurers that provide enhanced benefits for certain conditions. Moreover, the coding and insurance representatives of the CDT as well as AAE leadership and staff communicate periodically with insurance companies in efforts to resolve individual issues, including by speaking with dental directors of carriers at the meetings of the American Association of Dental Consultants. While we cannot ensure success, please contact the AAE at advocacy@aae.org should you have an insurance matter that you would like the AAE to investigate.

Srini Varadarajan is AAE’s assistant executive director for advocacy and professional relations.