AGD Policies

Adjusted for complying with governmental regulations

Methodology and source of funding must be disclosed if used for benefit determination

If information gathered from analyzed health care data is used for either benefit determination or dentist preferential selection, then the methodology and source of funding involved in the analysis must be publicly disclosed and verified by a process that ensures the quality, integrity, and validity of the analysis methodology.

Uses for, procedures must be publicly disclosed

The Academy of General Dentistry supports the concept that if health care data is analyzed, it should only be used to advance scientific knowledge or improve the oral health of the patient, while still allowing for professional judgments by practitioners.

The procedures involved in the analysis must be publicly disclosed and reviewed by the affected communities of interest in order to ensure the quality, integrity, and validity of the analysis methodology.

Appropriate charges made for administrative work

The AGD recognizes that it is ethical and proper for appropriate charges to be made when a dentist completes a claim form, a narrative report or other paperwork requiring secretarial, clerical, and professional time as long as the fee is identified.

Benefit coverage for dental surgery performed in office

The AGD supports the inclusion of clauses in hospitalization and surgical benefits contracts that provide for coverage for dental surgery in the office setting if such surgery would normally be covered were the patient hospitalized for the procedure.

Cash method of accounting, not accrual

The Academy of General Dentistry supports the use of the cash method of accounting, and not the accrual method, where preferred, by dentists engaged in the private practice of dentistry.

The Academy of General Dentistry communicates this position, when necessary, to legislative and regulatory entities.

Bill payer system

The AGD recognizes the 'bill payer system' (direct reimbursement) as one of the acceptable forms of dental prepayment.

Claim contested by dental consultant of

Should a patient's claim be contested by the third party's dental consultant, patient, or the patient's dentist, it shall be submitted to the local level of organized dentistry's peer review system and the third party, the patient, and the dentist should agree that the action of the peer review system is binding.

Considerations in deliberating dental health insurance programs

The Academy of General Dentistry takes into consideration the needs of the public, the various third party pre‑payment mechanisms, and the entire dental profession in deliberating on dental health benefits programs which might be of concern to the general dentists which compose its organization.

Consultant, ground rules for claims denial

When a third‑party dental consultant applies an alternative benefit provision to the treatment plan submitted by the provider dentist, or when a third‑party dental consultant denies benefits for reasons other than contract exclusions, the dental consultant must sign the report and provide his/her telephone number.

Consultant, should make no representation to patient regarding dentist's service or fee

When a patient's claim is considered for modification, and/or review, the third party dental consultant should contact the patient's dentist to discuss the matter fully rather than making any representation to the patient with respect to the dentist's services or fees.

Coordination of Benefits Guidelines

1. When a patient has coverage under two or more dental plans, the coverage from those plans should be coordinated so that the patient receives the maximum allowable benefit from each plan.  The aggregate benefit should be more than that offered by any of the plans individually, but not such that the patient receives more than the total charges for the dental services received.
2. In determining order of payment for benefits, the following rules should apply:

   a. The plan covering the patient other than as a dependent is the primary plan.

   b. When both plans cover the patient as a dependent child, the plan of the parent whose birthday occurs first in a calendar year should be considered as primary.

   c. When a determination cannot be made in accordance with the above, the plan that has covered the patient for the longer time should be considered primary.

   d. When one of the plans is a medical plan and the other is a dental plan, and a determination cannot be made in accordance with the above, the medical plan should be considered as primary.

3. In coordinating benefits with a dental plan which contractually reduces the fees for services which participating dentists accept as payment in full, the following rules should apply:

   a. When the reduced‑fee plan is primary and treatment is provided by a participating dentist, the reduced fee is that dentist's full fee.  The secondary plan should pay the lesser of its allowed benefit or the difference between the primary plan's benefit and the reduced fee.

   b. When the reduced‑fee plan is primary and treatment is provided by a non‑participating dentist, the reduced fee plan should provide its allowed amount for non‑participating dentists and the secondary plan should pay the lesser of its allowed benefit for the service or the difference between the primary plan benefits and the dentist's full fee.

   c. When a full‑fee plan is primary and a reduced‑fee plan is secondary, the full‑fee plan should provide its allowed amount for the service and the secondary plan should pay the lesser of:  its allowed benefit for the service or the difference between the primary plan benefits and the dentist's full fee.

4. In coordinating benefits between an indemnity and a capitation dental plan, the following rules should apply:

   a. When the capitation plan is primary, the capitation payments to the treating dentist remain the capitation plan's usual benefits.  The indemnity plan should pay benefits for the patient's surcharges or copayments up to the indemnity plan's allowable benefit.

   b. When the indemnity plan is primary, and treatment is received from a capitation‑participating doctor, the indemnity plan should pay its allowable benefits.  The capitation payments to the dentist are the secondary coverage since they constitute benefits up to the capitation plan's allowable amount.

   c. When the indemnity plan is primary, and treatment is received from a non‑capitation‑participating dentist, the indemnity plan should pay its allowable benefits.  The capitation plan will pay benefits, in keeping with the capitation plan's allowed amount for treatment by non‑participating dentists.

   d. No dental plan should contractually direct a dentist to charge a secondary carrier for more than the amount which would be charged to the patient absent secondary coverage.

5. Third‑party payers, representing self‑funded as well as insured plans, should be urged to adopt the above guidelines as an industry‑wide standard for coordination of benefits.
6. Constituent societies are encouraged to seek enactment of legislation that would require all policies and contracts that provide benefits for dental care to use these rules to determine coordination of benefits.

Third‑party payers, representing self‑funded as well as insured plans, should be urged to adopt these guidelines as an industry‑wide standard for coordination of benefits.

Constituent societies are encouraged to seek enactment of legislation that would require all policies and contracts that provide benefits for dental care to use these rules to determine coordination of benefits.

Co‑payment and overbilling, waiver of

The Academy of General Dentistry adopts policies regarding waiver of copayment and overbilling, which read:

Constituent dental societies be urged to pursue enactment of legislation that:

1. prohibits systematic non‑disclosure of waiver of patient co‑payment/overbilling by a dentist and
2. prohibits bad faith insurance practices by third party payers, consistent with Association policy.

Third‑party payers should be urged to support this legislative objective.

Dental Consultant

Must be a licensed dentist

The AGD recognizes that a dental consultant must be a duly licensed dentist within said state.

Dental insurance plan to include all facets of dentistry

The AGD recognizes that an optimum dental benefits plan includes all facets of dentistry.

Dentist's right to collect a larger fee from patient

The AGD is opposed to any administrative procedure by a third party payment mechanism which interferes with the dentist's right to collect from a patient a fee greater than that allowed by the carrier's benefit structure except when a dentist has agreed to become a participant in a benefits program that utilizes a usual, customary, and reasonable method of reimbursement as payment in full.

Differentials in levels of reimbursement in

The Academy of General Dentistry is opposed to differentials in levels of reimbursement in third party programs based on whether or not a practicing dentist is a 'participating' or 'non‑participating' dentist in such a program.
The AGD is unequivocally opposed to any type of separate fee schedules for reimbursement to general practitioners and specialists for the same or similar services.

Direct Reimbursement

Definition of

'Direct reimbursement' is defined as follows:

'Direct reimbursement is a self‑funded program in which the individual is reimbursed based on a percentage of dollars spent for dental care provided, and which allows beneficiaries to seek treatment from the dentist of their choice.'

Exclude ‘Least Expensive but Adequate’ Provisions

In the interest of providing the best possible level of dental care for the patient, the Academy of General Dentistry is opposed to the inclusion of 'least expensive but adequate treatment', 'alternate mode of treatment', or similar contract language, in prepayment dental plans.
Such language should be eliminated from prepayment contracts wherever possible.

This type of language in existing dental contracts should be implemented in such a manner so as not to impugn the integrity of the attending dentist or intrude upon the patient‑dentist relationship by either informing or implying that an alternate mode of treatment is appropriate, or influence the patient in any way in his choice of the attending dentist's treatment.

Fees, adjustment of

The Academy of General Dentistry recognizes that dentists may, upon occasion, adjust fees to classes of individuals, such as relatives, clergy, staff, senior citizens, and the indigent.
Any occasional fee adjustments should not be reflected in determination of UCRs by third parties. 

The Academy of General Dentistry recommends that this be properly recorded in the dentist's records.

Fee Determination

Third party payers should not determine fees for procedures not covered and/or not reimbursed in their policies.  

The appropriate AGD agencies should be directed to help AGD constituents develop legislation that will prevent third party payers from setting fees for non-covered and/or non-reimbursed procedures.

Fee schedules based on utilization reviews considered arbitrary

The Academy of General Dentistry believes that any fee schedule by third party dental benefit administrators or other entities that separates dentists into different payment levels as determined by statistically based ‘utilization reviews’ is arbitrary, discriminatory, and not consistent with appropriate patient care.

Fees; i.e., usual, reasonable, customary: definition of

The Academy of General Dentistry adopts definitions of and policies regarding 'usual, customary and reasonable fees,' which read:

'Usual fee' is the fee which an individual dentist most frequently charges for a specific dental procedure.

'Reasonable fee' is the fee charged by a dentist for a specific dental procedure which has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances, and therefore may differ from the dentist's "usual" fee or the benefit administrator's "customary" fee.

'Customary fee' is the fee level determined by the administrator of a dental benefit plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for the specific procedure.

Flexible Spending

The AGD supports the expansion of Flexible Spending Account (FSA) reimbursable health items to include oral health items.

Include all phases of preventive dental services

The AGD recognizes the necessity of having all phases of preventive dental services in the dentist's office included in dental prepayment plans.

Managed care, AGD's legislative priorities regarding

The AGD’s legislative priorities with regard to dental managed care encompass the following:

Patients will have the choice to select a plan with a point-of-service option, with reasonable cost-sharing requirements in premiums and per-service costs provided that those costs are not excessive.

Patients in a plan will be allowed to select their dentist, and change that selection as the patient feels is necessary.

The plan shall provide access to an adequate mix and number of dentists, including both general dentists and specialists, to ensure access to those services covered by the plan C including patients in rural and dentally under-served areas.

The plan shall allow patients with special needs to be referred to appropriate providers including specialists.

The plan shall provide an appropriate appeals and grievance procedure that allows for timely responses to patient and/or provider complaints.

The plan shall provide a dentist, licensed to practice in that state or province where the services are provided, to be responsible for dental treatment policies, protocols, and quality assurance activities.

The plan shall define and disclose limitations on coverage of experimental treatments and provide timely written justification for denial of such treatment to patients.

The plan shall not discriminate in participation, reimbursement, or indemnification against any dentist solely on the basis of his/her license.

The plan shall not prohibit or limit a dentist or other health professional from engaging in communications regarding the patient’s health status, health care, treatment options, or utilization review requirements.

The plan shall not provide any financial incentives to dentists, other health professionals, or reviewers to deny or limit care.

The plan shall provide dentists with reasonable notice of termination and allow the dentist to appeal such a decision and take corrective action if necessary.

The plan shall assume any liability resulting from the plan’s denying or restricting treatment or referral to specialists.

Mandated Health Benefits

AGD policy on:

The Academy of General Dentistry opposes federal and state laws mandating health and related benefits because such laws may increase health care costs, reduce employers' incentives to hire full time staff members, increase a trend toward underemployment of auxiliaries, and reduce incentives for employers to provide health care benefits since such laws place solo and small group practitioners at an economic disadvantage.

The Congress and the states should explore alternatives to government mandated benefits, including favorable tax incentives that encourage employer expansion of health care and related benefits.

Mandating preferred provider organizations

The Academy of General Dentistry opposes any federal legislation for the purpose of mandating preferred provider organizations, or pre empting state laws that regulate preferred provider organizations.

Medicare, amendment to reimburse dentists for rendering same service as a physician

The AGD supports the concept of amending Medicare so that a dentist shall be reimbursed for a dental service rendered under this program if a physician would have been reimbursed for rendering the same service.

Not to interfere with dentist's diagnosis and treatment

The AGD recognizes a third party payment mechanism's responsibility to determine its liability and extent of dental benefits but is unalterably opposed to any administrative procedure that interferes with the attending dentist's diagnosis and treatment plan.

Alternative payment systems for all dental care delivery should not infringe upon the right and responsibility of the licensed practicing dentist to diagnose and treat patients according to the proper standard of care.

Overpayment recovery practices

The Academy of General Dentistry opposes third party overpayment recovery practices, except as contractually obligated, when the overpayment was the result of a mistake made by the insurer and accepted by the dentist in good faith without prior or reasonable knowledge of the error.

The Academy of General Dentistry opposes third party payers from withholding fully assigned benefits to a dentist when an incorrect payment has been made to the dentist on behalf of the subscriber with the same third party payer.

Participation should not be contingent upon participation in government regulated programs

The retention of a license to practice dentistry and participation in third party plans should not be contingent upon participation in government regulated programs.

Preferred Provider Organizations

The Academy of General Dentistry supports the following concepts relating to preferred provider organizations:

A. Patients' freedom of choice of provider must be guaranteed.

B. Preferred provider policies or contracts and preferred provider subscription contracts shall provide the same benefits level to the patient whether rendered by non preferred providers or preferred providers.

C. No dentist willing to meet the terms and conditions offered by a PPO shall be excluded.

D. All types of licensed health care providers whose services are required shall have the same opportunity to qualify for payment as a preferred provider under any such policies.

E. The terms and conditions of any PPO policies or contracts shall not discriminate against or among health care providers.

F. A preferred provider subscription contract should be defined as a contract which specifies how services are to be covered by the plan when rendered by non participating providers and by preferred providers.

G. Preferred provider policies or contracts should be defined as insurance policies or contracts which specify how services are to be covered by the plan when rendered by preferred and non preferred providers.

H. When preferred provider organizations are promoted to the public, they cannot do so with any implications of superiority, and all promotional materials used by PPOs must state if a preferred provider is a reduced fee contract.

I. The PPO shall make provision for a periodic adjustment in level of reimbursement based on the Consumer Price Index or some other equitable basis.

Prepayment plans

Prohibit fee capping of non-covered procedures

The AGD encourages and supports federal legislation to prohibit fee capping of non-covered procedures by federally sponsored dental insurance plans.

Protect dental insurance as a fringe benefit

The AGD works to ensure that legislation would not adversely affect an employer's decision to provide dental insurance.

The AGD resist efforts being made by third party dental benefits programs to prohibit payment based on the specific technique used by the dentist to render treatment for the patient.

Reduction/denial of dental benefits must be signed by licensed dentist

The Academy of General Dentistry believes that any third party reduction or denial of dental benefits on the basis of ‘not medically necessary or appropriate’ must be made on an individual basis and signed by a dentist licensed in the state or province in which the procedures are being performed.

The Academy of General Dentistry believes that any third party reduction of dental benefits on the basis of ‘least expensive alternative treatment’ be made on an individual basis and signed by a dentist licensed in the state or province in which the procedures are being performed.

The Academy of General Dentistry believes that any review of clinical records for the purpose of reducing or denying dental benefits must be made on an individual basis and signed by a dentist licensed in the state or province in which the procedures are being performed.

Regulated by law or state governmental agency
All third party payment mechanisms should be regulated by law or through the appropriate state governmental agency to ensure fiscal responsibility and protection of the interests of the public.

Resource Based Relative Value Scale

The Academy of General Dentistry opposes use of the Resource Based Relative Value Scale as a method of determining payment for services provided by dentists.

Rights of employers to provide health care benefits

The AGD agrees in principle with the traditional rights of all employers to provide health care benefits for their employees.

Structuring of dental prepayment programs

Third party mechanisms, including government programs, take differences into consideration in structuring dental prepayment programs.

Dental prepayment programs for the non indigent have a provision whereby the patient will pay the difference between the fee authorized under the program and the normal fee charged.

Table of Allowances

Acceptable reimbursement mechanism

The Academy of General Dentistry endorses the table of allowances as an acceptable reimbursement mechanism.

Additional Reading 

"Dental to Medical Cross-Coding Tips"
"Exploring the Landscape of Leased PPO Networks"
"Measuring the Quality of Care"
"The McCarran-Ferguson Act: What a Repeal Could Mean for Dentistry"
"What to Know about the CDT Code"