Bundling and the New Utah Law

Utah was the first state to pass a law restricting bundling of procedures by dental insurance companies (third-party payers), which was a huge win for Utah dentists and the patients they serve. Front office team members know all too well how “bundling” affects the financial stability and patient relationships of any dental practice. Bundling of dental procedures is defined by the ADA as follows: “claims bundling is the systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient/beneficiary.” They go on to say, “The ADA considers bundling of procedures to be potentially fraudulent.”

Nothing could lack transparency more than a dentist performing two or three distinct CDT coded procedures that actually define what was performed on a patient, only to have an EOB (estimation of benefits form) “redefine” those services into something completely different, or worse, imply that the dental office billed incorrectly, leaving the patient wondering what actually was completed in their mouth, or worse, if their dental services were needed at all due to misleading verbiage on the above EOB.

The new Utah Law, House Bill 359, took a major step in the right direction, protecting dentists and their patients from the above frequently experienced scenario, and more. However, in this article, we will focus on the “bundling” component with Utah’s new law.

HB359 states, “An insurer may not maintain a dental plan that; uses bundling in a manner where a procedure code is labeled as nonbillable to the patient unless, under generally accepted practice standards, the procedure code is for a procedure that may be provided in conjunction with another procedure.”

Dental insurance companies can still bundle, but they cannot force you to write off separate services. Examples would be: bundling build-ups with crowns, gingivectomies and crown lengthening with crowns on the same day, diagnostics and treatment procedures with limited exams, and my favorite… bundling bitewings and panoramic x-rays into a full-mouth series. Are there others? Yes, but this is a good start to be aware of.

If a third-party payer becomes non-compliant with our new Utah law, and has verbiage on the EOB that is misleading, and they insist you follow their bundling guidelines, you need to consider filing a complaint with the Utah State Insurance Commission. Do not be afraid to file that complaint. Many think that filing a complaint will get you removed from being a provider to the dental insurance company you have filed against, but nothing could be further from the truth. The more complaints filed just strengthens our position. Having said that, many dental insurance companies understand our plight, and have already made changes to their contracts reflecting the new Utah Dental Law.

During the debates with the major insurance players, I brought up the question, “who determines what ‘generally accepted practice standards’ should be?” As they began to suggest it should be them, we clearly pointed out that it should be licensed dentists in our state, and no one else. The debate ended there. At the bottom of this article you will find a QR Code for “generally accepted practice standards” regarding targeted procedures by third-party payers. Only dentists are permitted to take the survey that will clearly define generally accepted practice standards. My advice would be to drop your altruistic dental hat, and place on your business hat when answering the questions so you don’t play into the hands of third-party payers. Enough said.

Our new Utah Dental Law regulates plans that are written here in Utah, for Utah companies. If it’s a federally run ERISA plan, or a plan written for a company in a different state, our Utah Law does not apply to those patients. Having said that, the UDA, MPMB, and other entities are working diligently to make those entities follow “state laws.” I can honestly state there has never been a more important time to support our dental associations than now. The fight is on, and we need everyone to support the battle that prevents third-party payers from coming between the doctor/patient relationship.

Let me be very clear on one major point: when dentists perform procedures that have codes and descriptions defined in the ADA CDT Code Book, or even worse, have codes, descriptions, and fees associated with them in their dental insurance contracts, and they do not charge their patient for those legitimate services, they are playing into the hands of those third-party payers to bundle, control, or eliminate those codes from their contracts and CDT Code Books. For those of you who have been practicing since the late 1980’s, you know exactly what I’m talking about. For example, medical charges for such things as local anesthetic and palliative treatment. Need I say more?

Third-Party Payers continually look for “frequency” of procedures, and ways to eliminate, or not pay for them, just to increase their profit margins. Through the years they have been able to eliminate the OSHA code, acid-etch and bonding, and others. In the early 2000’s they attempted to eliminate anesthetic, and more recently have gone after build-ups by “bundling” services until we are trained to no longer charge for them. Do you see the pattern? By eliminating their ability to “bundle” distinct dental procedures, dentists, and their teams, can be paid more fairly for the services they provide instead of doing free dentistry on insured patients.

Tracy Thorup, B.S., MBA

CEO, My Practice My Business

801-226-4420

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1 The American Dental Association, “Introduction to Dental Benefits” (online).

Accessed on 15 August 2021. Available at

[https://ebusiness.ada.org/assets/docs/2201.PDF?OrderID=339016].

2 https://ebusiness.ada.org/assets/docs/2201.PDF?OrderID=339016