ASSOCIATION UTAH DENTAL ASSOCIATION LEGISLATIVE SUCCESSES – RECENT YEARS TO THE PRESENT (Reprinted from Earlier edition of the UDA Action) From listening to dentist’s and their dental team members across the nation year after year, there is always a particular theme that surfaces to identify the most common #1 frustration in a dental office. That frustration is generally a frustration with dental insurance companies. More correctly identified as third-party payer companies. They are usually the #1 frustration in dental offices nationwide. Utah dentists and their dental team members definitely agree, third-party payers are their biggest frustration. Although the ADA nor UDA cannot dissolve the contracts a dentist has signed to be a PPO provider and accept lower reimbursements, the organization is still actively engaged in finding some resolve to the issues. Recognizing the dentist’s frustration, the ADA expanded the attempts a few years ago, to get involved with Insurance Reform across the nation. Several key topics began to surface, and efforts were put forth to see where changes or improvements could be made. Lots of effort was made to communicate state to state with successes and wording to initiate legislation in each state in regards to insurance reform. One of the early topics was Non-Covered services.
Non-Covered Services:
In 2016, the UDA with the help of Senator Allen Christensen and the ADA, proposed a bill that would be presented to the 2017 Utah Legislature. This bill passed the 2017 legislature and became law (statute) and went into effect Jan 1, 2018. Similar Non-Covered Services laws were passed in over 40 states. Showing the US Congress the importance and the need to address this in the US Congress and make this applicable to federally regulated third-party payers. For Utah, passing this bill in 2017 means: • A dental insurer is prohibited from setting fees for dental services that are not covered services under the dental insurance. • A contract between a dental plan and a dentist to provide covered services may not prohibit a dentist from offering or providing noncovered dental services to a covered individual at a fee determined by the dentist and the individual who will receive the noncovered services. • This does not apply to a dental plan that is regulated by federal law. • For exact language of the law, see Utah statute 31A-22646. • The state laws only apply to state regulated insurance plans. There are many dental plans that are under federal regulation.
More Recent Insurance Reform:
In the years since 2017, the ADA has been working on other third-party payer issues that continue to be a frustration to the dental team. The ADA identified several key frustrations and formed Dental Insurance Reform messages to assist states in achieving legislation that could ease some of the frustrations of the dental team, in regards to third-party payers. Four of those key topics developed with the help of the ADA, are: • • • •
Retroactive Denials of Coverage Prior Authorization Virtual Credit Cards Network Leasing
Let’s go over the significance of each of these areas and how the UDA has been able to make progress in Utah for dental offices on each of these common frustrations.
Retroactive Denials:
For those that may not understand what this term means, you all may be familiar with the actions that occur that are defined as Retroactive Denials. I myself, have been a victim of these efforts by third-party payers. Retroactive Denials are when an insurance company tries to require dentists to repay claims already paid to them when insurers discover they paid a claim mistakenly, even if the claim was processed years prior. In other words, an expected covered treatment is performed on a patient and the claim is processed and paid by the third-party payer. Then years later, the dental office receives a letter saying the office was overpaid and the office now owes the third-party payer a certain amount determined by the insurance company. It’s my understanding that often, the third-party payer strips out the “overpaid” balance out of other pending claims from other patients. This alleged overpayment notice comes at a time when an office can no longer legally go back to the original patient to bill for the performed services. In my case, the letter of “over payment” was received three years after treatment was performed. There is now a law in Utah that prevents this. The current recoveries language on Retroactive Denials applies to healthcare and is found in UCA 31A-26-301.6(14). This law is already on the books and does not allow an insurance company to come back years later to try to reclaim overpayments or claim disputes long after the date of service. The state Representative we have been working with, says the third-party payers only have 1 year from date of payment to try to reclaim the money. This time period is doubled for Medicaid claim overpayments.
UDA Action
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