UDA Legislative Successes 18 The Alternative P.P.P. Plan

UDA LEGISLATIVE SUCCESSES

(UTAH LAWS DISCUSSED AT RECENT UDA CQI MEETINGS)

Non-Covered Services (2017) SB 44 - Senator Allen Christensen; Rep Ray Ward see Utah statute 31A-22-646. 40+ states have passed similar legislation

• 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. • The state laws only apply to state regulated insurance plans. Many dental plans are federally regulated. Prior Authorizations: (2019) SB 264 Senator Evan Vickers and Representative Suzanne Harrison. See statute UCA 31A-22-650 .

In discussing Prior Authorizations, we should explain the

difference between Prior Authorization and Pre-Treatment estimates

A Prior Authorization means the third-party payer has agreed to make payment for the services being sought prior to treatment (Usually Written)

This Legislative bill spelled out that a Prior Authorization, if done correctly, would be more like a commitment or contract by the third-party payer for payment

Retroactive Denials: UCA 31A-26-301.6(14)

Nothing in this section may be construed as limiting the ability of an insurer to: (a) recover any amount improperly paid to a provider or an insured: (i) in accordance with Section 31A-31-103 or any other provision of state or federal law; (ii) within 24 months of the amount improperly paid for a coordination of benefits error; (iii) within 12 months of the amount improperly paid for any other reason not identified in Subsection (14) (a)(i) or (ii); (iv) within 36 months of the amount improperly paid when the improper payment was due to a recovery by Medicaid, Medicare, the Children's Health Insurance Program, or any other state or federal health care program;

Virtual Credit Cards: (2020) HB37 - Representative Jim Dunnigan and Senator Curtis Bramble See UCA 31A-26-301.6

This gives dental offices an option to accept or opt out of Virtual Credit card payments methods. Thus, saving the office from the credit card fees associated with credit card payments.

This bill gives dental offices an option to accept or opt out of Virtual Credit Card payment methods. Network Leasing: (2021) HB 359 Representative Jim Dunnigan and Senator Karen Mayne See UCA 31A-22-646.1

When a dentist signs up with a third-party payer to be a provider, the third-party payer leases that contract to other third-party payers. Now the dental office is contracted with more plans than they are often aware.

Network Leasing Plan Requirements

86 if the contracting entity is an insurer, a provision indicating: 87 that the contract grants a third party access to the provider network; and 88 for a contract with a dental carrier, the dentist has the right to choose not to 89 participate in third-party access 95 require a third party to identify the source of the discount on all remittance advices 96 or explanations of payment under which a discount is taken unless the transaction is an 97 electronic transaction mandated by the Health Insurance Portability and Accountability Act; 98 notify a third party of the termination of a provider network contract no later than 99 30 days after the day on which the contract terminates with the contracting entity; 100 at least 30 days before the day on which a third party begins leasing a network

Network Leasing (continued)

101 provider, notify each network provider subject to the lease; 102 make available to a participating provider, within 30 days after the day on which the 103 provider makes a request, a copy of the provider network contract at issue in the adjudication 104 of a claim; and 105 maintain a list of the contracting entity's affiliates on the contracting entity's 106 website.

Also as part of 2021’s HB 359, See UCA 31A-26-301.7. 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.

Downcoding, Bundling, EOB Verbiage 153 An insurer may not maintain a dental plan that: 154 based on the provider’s contracted fee for covered services, uses downcoding in a 155 manner that prevents a dental provider from collecting the fee for the actual service performed 156 from either the plan or the patient; or 157 uses bundling in a manner where a procedure code is labeled as non-billable to the 158 patient unless, under generally accepted practice standards* the procedure code is for 159 a procedure that may be provided in conjunction with another procedure. 160 An insurer shall ensure that an explanation of benefits for a dental plan includes the 161 reason for any downcoding or bundling result.

What Does This Mean?

• Insurance Companies can still downcode & bundle, but: • They cannot force you to write off a separate service • If they don’t pay, THE PATIENT PAYS! • Examples: • Third Party Payors EOB’s stating to write off a build-up • Gingivectomy with crown prep • Crown lengthening with crown prep • Non-coded technology with treatment • Any pulp caps with fillings • Four quads of SRP at same appointment • Any diagnostic or treatment codes with limited exams • Bitewings and Pano to FMX • Many others…

* My Practice My Business and the Utah Dental Association are teaming up to establish what generally accepted practice standards are in a dental practice. In order to best establish the standard, a Dentist should access the following survey, what they consider to be practice standard. The survey will only take a couple of minutes.

Help the Utah Dental Association and My Practice My Business (Dr Rod and Tracey Thorup) document what are Generally Accepted Practice Standards in Utah Dental Offices. Help the Utah Dental Association and My Practice My Business (Dr Rod and Tracey Thorup) document what are Generally Accepted Practice Standards in Utah Dental Offices.

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