Utah Dental Association Legislative Successes

Year after year, there is always a certain amount of frustration in a dental office. The one topic that usually causes the most frustration amongst all offices, is “dental insurance” issues. More correctly identified as third-party payer issues. That frustration generally originates from problems created by the third-party payer companies. In August of 2022, the UDA sent out a survey asking which third-party payer issues were the most frustrating. (See below). This frustration is almost unanimous across all dental offices nationwide. Utah dentists and their dental team members definitely agree, third-party payers are their biggest frustration.

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 Association insurance. • A contract between a dental plan and a dentist to provide covered services may not prohibit a dentist from offering or UTAH DENTAL ASSOCIATION LEGISLATIVE SUCCESSES providing noncovered dental services to a covered individual at a fee determined by the dentist and the individual who Year after year, there is always a certain amount of frustration in a dental office. The one topic that usually causes the most frustration amongst all offices, is “dental insurance” issues. More correctly identified as third-party payer issues. will receive the noncovered services.That frustration generally originates from • This does not apply to a dental plan that is regulated by problems created by the third-party payer companies. In August of 2022, the UDA sent out a federal law.survey asking which third-party payer issues were the most frustrating. (See below). This frustration is almost unanimous across all • For exact language of the law, see Utah statute 31A-22-646dental 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, our organization is still actively engaged in finding some resolve to the third-party payer issues. Recognizing the dentist’s frustration, the ADA expanded the attempts a few years ago, to get involved with “Dental 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. States are sharing with other states, their legislative strategy, and their legislative successes. One of the early topics pushed in state legislatures 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.

Q3: I am experiencing issues related to: (check all that apply)

Carrier Overpayment Creden/aling/Retroac/ve Payments Virtual Credit Cards Retroac/ve Denial of Prior Authoriza/ons Network Leasing (aka Silent PPO's) Assignment of Benefits Non-Covered Services/Capped Fees Pre-paid Dental Corpora/ons Exclusive Networks Medical/Dental Loss Ra/o Downcoding Bundling of Procedures Least Expensive Alterna/ve Treatment Clauses Explana/on of Benefits (EOB) Coordina/on of Benefits (COB)

Powered by

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

More Recent Insurance Reform:

In the years since 2017, the ADA and UDA have 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

Although the ADA nor UDA cannot dissolve the contracts a dentist has signed to be a PPO provider, our organization is still actively engaged in finding some resolve to the third-party payer issues. Recognizing the dentist’s frustration, the ADA expanded the attempts a few years ago, to get involved with “Dental 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. States are sharing with other states, their legislative strategy, and their legislative successes. One of the early topics pushed in state legislatures 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. 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 a third-party payer tries to reclaim money already paid to the dentist, 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 months or 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 “over-paid” balance out of other pending claims from other patients. This alleged overpayment notice often 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.

Prior Authorizations:

In discussing Prior Authorizations, we should explain the difference between Prior Authorization and Pre-Treatment estimates. Usually, Pre-Treatment estimates occur when an office staff calls the third-party payer and tries to find out the extent of coverage, if certain procedures are performed. This pretreatment estimate is not technically a Prior Authorization. A Prior Authorization means the third-party payer has agreed to make payment for the services being sought prior to treatment (usually this is done in writing, and possibly after dental consultant review).

The concern with dental offices is an increasing number of insurers are denying claims for services previously authorized, reversing their agreement with both patients and dentists. In 2019, SB 264 regarding to Prior Authorizations passed. The Bill was sponsored by Senator Evan Vickers and Representative Suzanne Harrison. This Legislative bill spelled out that a Prior Authorization, if done correctly, would be more like a contract or commitment by the third-party payer for payment. When a dental office has received a prior authorization and the third-party payer elects to not honor that prior authorization, the office should appeal to the third-party payer company citing the Utah law, reminding them the law states they are committed to the payment they acknowledged in the prior authorization. See statute UCA 31A-22-650 .

Virtual Credit Cards:

This is a term given to the process where an insurance company reimburses a dental office through a virtual credit card, which can include a per-transaction fee of as much as five percent. In some cases, insurance companies even share in the revenue generated from these fees. You likely have seen this as a letter that contained a 16 digit credit card number that your office is to run the number through your credit card services as if you were being paid with an actual credit card. This results in an additional loss of income since a percentage was removed by the credit card services company.

In the 2020 Utah Legislative session, the UDA advocated for language in HB 37, that would allow a dentist to opt out of Virtual Credit card payment methods. Thus, saving the office from the credit card fees associated with credit card payments. Representative Jim Dunnigan and Senator Curtis Bramble sponsored an insurance Amendments bill and worked with the

Contact me to fi nd out how you can

Matt Hamblin Utah, Nevada & Southeast Idaho practice sales associate placements partnership agreements mergers succession planning practice valuations DSO negotiations

UDA to give dental offices an option to accept or opt out of Virtual Credit card payments methods.

The dentist needs to notify the third-party payer that they want to opt out of Virtual CC payments and inform them you want to receive payment by check. The Utah law says they can request the opt out for the dentist from that particular third-party-payer company. The dentist would have to repeat this notification for every third-party payer company they participate with. It is not automatic. The dental office will have Utah law backing them when they request to opt out. See UCA 31A-26-301.6

Some insurance companies were making the dentist specify each patient they were opting out on. The new law says they can tell that Insurance company they opt out for all their payments from that company. The dentist should clarify, they want the Ins Co to pay them by check rather than Virtual Credit card.

Network Leasing:

Many may not recognize the term Network Leasing. Network Leasing is when third-party payers sell participating dentists to a different insurance network often without the dentist’s knowledge or consent. Basically, when a dentist signs up with a third-party payer to be a provider for them, the third-party payer leases that contract to other third-party payers. This can result in the dental office being contracted with several additional PPO plans. The dentist may not even be aware of all the dental plans of which they are then contracted. This can significantly impact the insurance benefits available to the patients. Often the dental office will be reimbursed at the lowest rates of those companies in the network. This also erodes patient/dentist trust, which can lead to assumptions in treatment plans and costs based on a false understanding of patient coverage.

In preparation for the 2021 Legislative session, the UDA was working with Representative Jim Dunnigan to craft a bill creating transparency and options for a dentist in regards to Network Leasing. The National Council of Insurance Legislators (NCOIL) and the ADA had been working on model legislation that would help solve many dentist’s frustration with Network Leasing. The ADA, various State Legislators, and many Insurance Companies had already vetted this topic for months and had come to several agreements for transparency. The result was the NCOIL Model Legislation. The UDA used this model legislation in initiating a bill for the 2021 legislative session (HB 359 sponsored by Representative Jim Dunnigan and Senator Karen Mayne). See UCA 31A-22-646.1

Since the Fall of 2020, the UDA has worked with Dr Rob and Tracy Thorup of “My Practice, My Business”, in specifically creating legislation regarding HB 359. Their additional ideas presented included two topics that were included in the 2021 HB359. Many hours of work with Representative Jim Dunnigan, the UDA and Dr Rob & Tracy Thorup were put in to finally create the final version of HB 359. The Thorups, UDA Representatives and Rep Dunnigan virtually met for several weeks and brought in many representatives of the larger insurance companies. The discussions resulted in some understanding of the dentist’s frustrations caused by these thirdparty payers in regards to Bundling and Downcoding.

As part of 2021’s HB 359, An insurer may not maintain a dental plan that: • based on the provider’s contracted fee for covered services, uses downcoding in a manner that prevents a dental provider from collecting the fee for the actual service performed from either the plan or the patient; or • 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.

Also, an insurer shall ensure that an explanation of benefits for a dental plan includes the reason for any downcoding or bundling result. See UCA 31A-26-301.7. or HB 359 (2021)

There had been a great deal of significant effort made to negotiate and resolve conflicts with third-party payer companies during all aspects of the crafting of this bill. As a result, HB 359 was placed on consent calendar for both the House and Senate. This essentially means, enough debate and crafting took place before the writing of this bill, that it sailed through legislation unopposed. This was a great “Win” for Utah dental offices on insurance reform topics made possible by the efforts of the UDA and My Practice, My Business (Dr Rob and Tracy Thorup).

We again are currently working on additional legislation with “Dental Insurance Reform” issues for the 2023 Legislative session. We will continue to work on ways to find solutions to the often-frustrating tactics used by third-party payers. Regardless of our legislative efforts, the high PPO participation by dentists in Utah still directly determines the declining dental reimbursement rates. We continue to educate and encourage dental offices to look at the PPO’s they are “in-network” and make wise business decisions by taking control of your circumstances, rather than be controlled by your circumstances.

In Summary, although legislation intends to improve and sustain what is best for the public and professions such as dentistry, there are always plenty of groups out there trying to take advantage of well intending practitioners. Legislation that will only contribute to sustaining and maintaining the dental profession as we currently know it, is not likely. Between the DIY dental companies, the trend toward mid-level providers, and growing aspects of DSO’s, and other groups working to fragment dentistry, the profession we love is gradually and significantly changing. The UDA is constantly defending and encouraging dentists and their dental team members to provide the best oral care for the public. If we remain united and do not become a fragmented profession, we will be better able to direct Legislative and Congressional successes, maintain public safety and improve sustainable oral health care.

Dr Val L Radmall UDA Executive Director