ADA dispute against Delta Dental policy escalates

June 30, 2016

By Kelly Soderlund

The ADA took its dispute with Delta Dental a step further in June when the Association’s executive director and president sent the third-party payers CEO a letter expressing their “serious concerns and extreme disappointment” over its disallow policy.

Drs. Carol Gomez Summerhays, ADA president, and Kathleen O’Loughlin, ADA executive director, sent Steven R. Olsen, president and CEO of Delta Dental Plans Association, a letter June 20 detailing their discontent with a Delta policy to not cover unique procedures performed or proposed in good faith by dentists participating in the plan. In this scenario, if Delta deems a procedure unnecessary, the plan denies coverage for the patient and invokes a contract provision preventing the dentist from billing the patient, often resulting in the patient not receiving necessary services to achieve optimal oral health, the ADA leaders wrote.

“By ‘disallowing’ a service, and thus determining definitively that a service does not need to be performed, third-party payers are effectively interjecting the plan into the doctor-patient relationship, contravening the professional judgment of a qualified and duly licensed dental professional,” Drs. Summerhays and O’Loughlin wrote. “When that determination occurs prior to the performance of the procedure, the payer places the dentist in the ethical dilemma of declining to perform the procedure that he or she feels to be necessary or, alternatively, of performing the procedure without hope of compensation.”

This is the second letter ADA representatives have sent Delta regarding their policies on whether to cover certain dental procedures for patients. The Council on Dental Benefits sent Dr. Bill Kohn, vice president of dental science and policy at Delta Dental, a letter April 27 asking the company to reject a proposed policy that would automatically disallow claims where more than two quadrants of scaling and root planing were performed on the same date of service. The company did not officially respond to the statement.

“Because Delta was not receptive to our first pass at trying to change their minds about a policy that greatly affects dentists, we felt it was prudent to send a more forceful letter to get our point across,” Dr. Summerhays said. “It’s the ADA’s job to advocate for our members, and if there’s a company that’s putting them in a position where they’re asked to compromise patient care in order to reduce the company’s claims cost, we intend to go to battle on their behalf.”

The ADA contends that third-party payers are not in a position to be determining which services need to be performed.

“As a professional association for dentists, it’s our responsibility to advocate for our members and help them provide the best patient care,” Dr. O’Loughlin said. “This policy doesn’t allow that. This policy may prevent patients from receiving treatment or services that is necessary to achieving optimal oral health. While some payers may point to overuse of certain procedures by some dentists, universal disallow policies that apply to every dental practice are unfair.”

Patient care and treatment decisions should be made in an informed partnership between the patient and qualified and duly licensed dental professionals, the ADA leaders said.

“On behalf of dentists and the patients they serve, the ADA feels compelled to highlight this too often unfair business practice by the dental payer industry whose goal appears to be reduced claims cost, rather than optimal patient outcome,” Drs. Summerhays and O’Loughlin wrote. “We urge you to remove ‘disallow’ clauses from participating dentist agreements and cease disallowing health care services that are of importance to patients and the purchaser of the health benefit.”  

Delta Dental did not respond to an ADA News request for comment.

To read the full letter and to learn more about how the ADA helps members with dental benefits issues, visit ADA.org/dentalplans and click on “Member Support on Third-Party Issues.”