Insurance
Roughly 211.7 million Americans, or 66 percent of the population, use dental insurance to receive the oral health care they need. AGD is working with legislators to eliminate insurance issues such as fee capping, unfair pricing and regulations that limit consumers’ ability to use their benefits.
Fee Capping: Several major dental benefits carriers set fees for dental services that are not covered under their plans. However, some states have introduced legislation to prohibit this practice, also known as fee capping.
Carriers maintain that holding dentists to a maximum charge for non-covered services allows patients to receive procedures that they otherwise might not seek. However, fee capping disrupts long-standing patient-dentist relationships and forces private-pay patients to absorb the additional costs incurred by the dentist. This practice also relieves carriers’ obligation to provide coverage for a wider range of services, which ultimately would improve access to care.
Dentists and patients should be allowed to agree on payment terms that fit the patient’s needs while allowing the dentist to operate a successful practice and provide the best possible care. AGD has been collaborating with the American Dental Association and other organizations to support legislation preventing fee capping.
While these efforts have proven successful in some states, these states do not have jurisdiction over all dental benefits carriers, so organized dentistry is pursuing solutions at the national level as well.
One solution is H.R. 1606, the Dental and Optometric Care Access Act (DOC Access Act), sponsored by Rep. Earl “Buddy” Carter (R-Georgia). This legislation would prohibit “non-covered services” provisions that dictate what a provider may charge a plan enrollee for items or services not covered by the plan. Under H.R. 1606, providers will be able to charge a fair and customary amount for non-covered services rather than be subjected to an insurer’s mandated fee schedule, a long-overdue change that will eliminate anti-competitive practices in health care and improve the overall quality of patient care.
H.R. 1606 is narrowly drawn to apply only to the business of dental and vision insurance plans regulated by the federal government. This legislation would not interfere with the states’ ability to maintain and enforce their own insurance regulations and laws, but rather compliment the work already undertaken by most state legislatures across the country.
AGD encourages lawmakers to provide fairness in contracts between providers and insurers, increase the quality of care for patients, and protect consumers from anti-competitive practices by cosponsoring the DOC Access Act or by introducing similar legislation in the Senate.
McCarran-Ferguson Act: Rep. Paul A. Gosar, DDS (R-Arizona), sponsored H.R. 372, the Competitive Health Insurance Reform Act of 2017. This legislation would repeal the provisions found in the McCarran-Ferguson Act that exempt health and dental insurance plans from federal antitrust laws. This would allow federal agencies to investigate and challenge collective action by insurance companies, and enable those impacted by illegal practices to take corrective action. By curtailing anti-competitive practices in the health insurance industry, H.R. 372 would promote a greater range of options for patients and more appropriate reimbursement rates for health care providers.
In the absence of federal oversight, regulation of the insurance industry will continue to be left to the states, which often lack the time and resources to effectively investigate antitrust claims, leaving anti-competitive activities largely unchecked. This must change because competition is necessary for innovation and fosters variety in the marketplace.
AGD urges lawmakers to support efforts to repeal the antitrust exemption found in the McCarran-Ferguson Act for health insurance.
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"