Legislature passes MDA Dental Fair Contracting bill
The MDA is pleased to announce that the MDA’s Dental Fair Contracting bill was passed by the legislature and then signed into law by Governor Dayton on May 24. Negotiations between all interested parties related to the Dental Fair Contracting bill were initiated by key legislators, resulting in Delta Dental of Minnesota and other insurers agreeing to the final bill language detailed below. Delta also agreed to make changes to the audit provisions in its Policies and Procedures Manual. Additionally, the new law contains a section addressing dentist billings for non-covered services that was agreed to by Delta and other insurers. Here is a summary of the bill that passed and the changes Delta has indicated it will make to its Policies and Procedures Manual.
Chapter 64 of the Laws of Minnesota for 2011
The MDA Dental Fair Contracting Law amends state law by adding new provisions relating to contract amendments, provider audits, and covered services. All of these provisions were agreed to by Delta Dental and other insurers. Here is what these new provisions provide.
- An amendment or change in terms of an existing contract between a dental organization and a dentist must be disclosed to the dentist at least 90 days before the effective date of the change.
- A written explanation to the dental provider of the reason for their audit and the process the dental organization intends to use to audit patient charts, as well as an explanation of the processes available to the provider once the dental organization completes its review of the audited patient records must be provided.
- A provider must be allowed a reasonable period of time from the date that the provider receives the verified audit or investigation findings to review, meet, and negotiate a resolution to the audit or investigation.
- A licensed dentist whose license is in good standing must be used by the insurer to review patient charts.
- No dental contract with a dentist may require, directly or indirectly, that a dentist provide services to an enrolled participant at a fee set by, or at a fee subject to the approval of, the dental plan or dental organization unless the dental services are covered services.
- “Covered services” means dental care services for which a reimbursement is available or for which a reimbursement would be available but for the application of contractual limitations such as deductibles, co-payments, coinsurance, waiting periods, annual or lifetime maximums, frequency limitations, alternative benefit payments, or any other limitation.
Delta Dental Policies and Procedures Manual Changes
Based on the discussions, Delta Dental has indicated it will amend its Policies and Procedures Manual in the following ways:
- Audits shall not look back more than 42 months with the exception that public program audits and potential cases of fraud will not be so limited.
- Participating dentists will be given a minimum of 120 days advance notice of amendments to the Policies and Procedures Manual.
- A dentist or clinic will receive written notification of audit results within 120 days of receipt by Delta of all materials requested.
- Results of an audit will be communicated in writing, and will include a list of patient charts reviewed, the amount of statistical projections made by Delta, a copy of any statistical models/formulae employed in making any statistical projections, and, when available, the chart or graphical depiction of audit findings including peer comparisons.
- Language authorizing Delta to assess audit related costs such as legal fees, administrative costs, consultant expenses, and other costs will be dropped from the Policies and Procedures Manual.
- A dentist may terminate their membership with Delta upon a 30 day notice as long as patients are adequately communicated with.
- Statistical projections (extrapolations) will only occur when the audit findings are shown to be statistically significant using generally accepted statistical models that employ “p-value” and “null hypothesis” methodologies. In addition, audit findings must be financially significant by involving more that $1,000 in order for statistical projections (extrapolations) to be utilized.
- Withholding of monies sought from a dentist based on an audit may not begin until 75 days after a meeting on the audit findings or 150 days after the notice of audit is mailed. When withholding occurs, a maximum of 35% of claim payments may be withheld up to a total of 35% of the amount sought from the audit findings.
The MDA would like to thank its chief legislative authors, Senator Ray Vandeveer (R-Forest Lake) and Representative Greg Davids (R-Preston) for their support and effort in accomplishing this successful outcome. The Senate passed the Dental Fair Contracting Bill 53-0 and the House passed it 133-0.