AADC Position Statement Regarding Licensure of Dentist Consultants
Over the year there have been proposals to require any dentist who reviews a claim for dental services to be licensed in the state in which the services are rendered. For example a dentist reviewing a dental claim in California (on behalf of an insurance carrier located in California) would be required to possess a New York dental license if the services on the claim being reviewed were rendered in New York.
This type of proposal affects millions of consumers. There are over 164 million Americans fortunate to have dental coverage. Consumers receiving dental services in a state other than the one in which the claim is being processed will be affected by any legislative mandates, promulgation of rules, or misinterpretations of existing regulations. This includes consumers who require dental services while traveling. Dental license is specific to a state. This means that dental consultants would need ato be licensed in all state or the dental carrier could potentially need to hire consultants in each state which eliminated efficiencies and drives up the cost to administer a dental plan. In effect, approximately 20,000 licenses would be required for the number of dentist members of the AADC who now review claims from anywhere in the country.
Enactment of the proposed dental consultant licensure regulations will impair dental claims review efficiency, inject unneeded complexity into the administration of dental claims, seriously weaken vital cost containment and quality assurance activity, delay payment of dental claims and drive up both the administrative and benefit costs of dental insurance. Dental insurance will become less affordable. The public will pay more in both out of pocket and premium costs for the same coverage they have now.
Increased costs will cause some to lose coverage and prevent others from obtaining coverage. Increased cost and lack of dental insurance will create financial barriers to dental care and the oral health and well being of the public will suffer.
Claims review is not the practice of dentistry. The AADC is in total disagreement that making a payment determination is the equivalent to practicing dentistry. In some instances there is a need to have the background, education and training of a dentist in order to render certain benefit determinations. This first set of skills is acquired through the process of becoming a dentist. In addition the dentist must receive additional training to become knowledgeable regarding the dental consultant’s claims review function in light of the covered person’s contract benefits. This second set of skills is acquired through training by the carrier and participation in courses offered by organizations such as the AADC. Although it requires a specific body of knowledge, making a benefit determination is not the practice of dentistry. Similarly, teaching a dental continuing education course or providing expert opinion in a malpractice case requires a specific body of knowledge but does not constitute the practice of dentistry.
Meeting the separate license requirement is unrealistic for the individual consultant. Requiring that a dentist consultant be licensed in every state from which he might receive a claim is unrealistic, impractical, and virtually unobtainable for the individual consultant. Since on any given day a claim may arrive from anywhere in the United States, the individual consultant would need to maintain 50 different dental licenses. Obtaining the 50 licenses would require meeting the qualifying criteria, taking the licensure examination, meeting the license maintenance requirements, and payment of the necessary license fees and travel costs associated with taking the various examinations. All of these items may vary from state to state. Some states participate in regional examinations and some states offer reciprocity with other states. However there is no national reciprocity and the process of acquiring the prerequisite licenses would be an extremely arduous, costly, and time-consuming effort.
Compliance will seriously reduce the efficiency of claims review, inject administrative complexity, and delay claims payment.
Dental consultants possessing licenses in all 50 states will not be available. Therefore the dental carriers will be faced with the overwhelming administrative burden of finding the required number of dental consultants and setting up operations to match the out of state claim with the consultant possessing the corresponding state license. This task presents a host of administrative issues. Claims will have to be separated by state and directed to the consultant with the license in that state. They may have to be mailed to the consultant. It is not feasible to keep enough consultants in house every day claims are processed in order to have the consultant with the corresponding license available. Delaying claims payment until the scheduled workday for the consultant with the corresponding state license may be the only other option. As these examples illustrate the proposed regulations present a myriad of compliance problems that will seriously reduce the efficiency of claims review, delay claims payment, and inject administrative complexity.
The long-term effect of compliance on dental benefit programs will be to drive up the cost and lower quality. Dental carriers are facing stringent regulatory claims payment deadlines. Failure to meet these deadlines usually results in interest and fines to the carrier. Therefore in this “prompt pay” regulatory environment the long-term result of compliance with the additional burdens imposed by the dental consultant licensure regulations will be two fold:
(1) The increased administrative costs necessary to meet the consultant licensure regulations will reduce the financial resources available for dental benefit payment (unless premiums and/or administrative fees are raised).
(2) The additional costs (unless premiums and/or administrative fees are raised) will foster the elimination or reduction of the dental consultant claims review.
Dental claims review is the most cost effective mechanism available to dental benefit programs to ensure that the dental services submitted for payment are necessary, appropriate, meet the standard of care and are benefits under terms of the insured member’s contract. In either scenario the effect of implementing the proposed policy is to seriously drive up the cost and lower the quality of dental coverage.
The ultimate effect of the proposed regulation will be to raise dental costs and consequently harm the oral health and well being of the public.
The Surgeon General of the United States has reported that there is a “silent epidemic” of oral disease among the most vulnerable members of our society. The report also correlates the lack of dental insurance with poor oral health,
“The data indicate that lack of dental insurance, private or public, is one of the several impediments to obtaining oral health care and accounts in part for the generally poorer oral health of those who live at or near the poverty line, lack health insurance or lose their insurance upon retirement. “
Consider the following data from the report in support of this position:
Over 108 million children and adults lack dental insurance.
Employed adults lose more than 164 million hours of work each year due to dental disease.
Dental caries is the most common childhood disease – 5 times more common than asthma and 7 times more common than hay fever.
More than 51 million school hours are lost each year to dental-related illness.
Uninsured children are 2.5 times less likely to receive dental care.
Children from families without dental insurance are three times more likely to have dental needs than children with either public or private insurance.
For each child without medical insurance there are at least 2.6 children without dental insurance.
Donna E. Shalala, Secretary of Human Services at the time of the release of the report states in the introduction:
“Oral health is integral to general health: this report provides important information that oral health means more than healthy teeth and that you cannot be healthy without oral health.”
Later in the introduction she states:
“ This Surgeon General’s report addresses the inequities and disparities that affect those least able to muster the resources to achieve optimal oral health. For whatever reason, ignoring oral health problems can lead to needless pain and suffering, causing devastating complications to an individual’s well-being, with financial and social costs that significantly diminish the quality of life and burden American society.”
As stated previously, compliance with the proposed regulations will cause the public to pay more in both out of pocket and premium costs for the same coverage they have now. Increased costs will cause some to lose dental insurance and prevent others from obtaining dental insurance. Lack of dental insurance is associated with poor oral health and the damaging financial, social, and human consequences poor oral heath brings to our society.
The end result of these burdensome and costly regulations will be to render dental insurance less affordable for the most vulnerable members of our society. Lack of dental insurance and the financial barriers it presents to dental care will have a detrimental effect on the oral health and well being of the American Public. Therefore the American Association of Dental Consultants strongly opposes the adoption of such regulations.
About the American Association of Dental Consultants
The American Association of Dental Consultants is the only organization specifically for dental consultants in the United States. AADC is composed of dentists, persons involved in the administration of dental benefit programs, educators lecturing or writing on the subject, and others who contribute to the advancement of the objectives of the association.
Its purposes are –
To establish an avenue of communication for its members
To encourage them in advancing their qualifications so that they can best serve the interests of dentistry, dental benefit plans, patients, and policyholders
To insure the competency of all its members through the certification process, this is one of the outstanding features of membership. Persons having been certified by the AADC are recognized as being leaders in the field
Since its founding in 1979, AADC has thrived in a world of change. Today, AADC is the professional organization of choice for more than 300 members in numerous countries. AADC members are dedicated professionals in dental consulting, administration, and education. A voluntary board of directors elected by our members governs AADC. Day-to-day operation of the association is carried out by an executive director.
Position Statement approved by AADC Board of Directors October 15, 2019