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SPECIAL COMMUNICATION

AMERICAN DENTAL ASSOCIATION


COUNCIL ON DENTAL BENEFIT PROGRAMS


Ethical considerations in dental plan


claims adjudication
Dave Preble, DDS, JD; on behalf of the American Dental the patient, thereby crossing over into actual inuence
Association Council on Dental Benet Programs on the treatment options offered by the dentist and
treatment acceptance decisions by the patient. If the

T
dentist cannot be paid for the service, either through
he American Dental Association Council on the patients benet plan or by the individual patient,
Dental Benet Programs receives inquiries from then the dentist is precluded from rendering the service,
members on many topics. This topic deserves even if this is a service the dentist recommends for the
investigation on an ethical level, aside from the welfare of the patient.
tactical advice usually given. One example of a procedure that is disallowed is that
One question we received was from a member who 3 or more quadrants of scaling and root planing per-
said that part of his contractual agreement as a partici- formed on the same visit are automatically disallowed.
pating provider allows dental plans to disallow treat- Not only will no benet be paid, but the dentist is pro-
ment. This means the plan can prevent him from billing hibited from billing the patient, effectively preventing the
the patient in addition to denying benets, which treatment from being rendered. There are other exam-
essentially precludes him from performing the service ples, but this example is used to illustrate the effect of
even though, in his professional judgment, the treatment disallowance because there may be some agreement by
is necessary and the patient has been appropriately dentists that there is a potential for this procedure to be
involved in the decision. Are there ethical issues for the misused. The point is that regardless of a desire to curb
third-party payer, the dental consultant, and me? asked abuse, this is the wrong way to do it. Let us think that
the member. through.
Dental benet plans are increasing their inuence Benet plans express concern over improper treat-
over treatment decisions of contracted dentists through ment as justication for moving beyond denial of
processing policies such as you describe. A number of benets into a disallowance of the treatment. To be
ethical questions come to mind, if not for the third-party clear, this decision is being made unilaterally by the
payer as a business entity, then for the licensed dentists benet plan and forced on the participating dentist
acting as consultants and for the dentists performing the based on his or her contractual agreement with the
treatment. First, let us explore what has prompted this benet plan. The ultimate effect, therefore, is to pre-
question. clude the dentist from delivering the service without
Purchasers of dental benet plans decide which regard to the therapeutic value of the care or the
services are covered through their plan purchasing patients preference for that treatment from the options
decisions. Benet plan administrators may deny benets offered by the provider as a fully informed consumer
based on the terms of the contract. However, a new form of health care.
of benet decision is now being made that surpasses the This form of claim adjudication creates a direct effect
normal business decision of approving or denying on patient care rather than the indirect effect on patient
benet payment. This new benet decision is called care caused by benet denial. The patients decision may
disallowance (dened by a processing policy manual then be inuenced based on cost, but it does not prevent
of a major dental benet plan as Disallowed - No the service from being rendered. When benet payment
payment is made by . nor is collectable from the pa- is denied, the patient may still exercise the right to
tient by a participating dentist.) because the third-party choose treatment by paying out of pocket. The important
payer not only denies payment of a benet but distinction is that disallowance does not allow the dentist
contractually prevents the treating dentist from billing to bill the balance to the patient.
Another example that may provide more clarity is
that a crown is disallowed if a determination is unilat-
Copyright 2017 American Dental Association. All rights reserved. erally made by the plan that either there is enough tooth

JADA 148(6) http://jada.ada.org June 2017 407


SPECIAL COMMUNICATION

structure remaining to be restored more conservatively challenging the dentists expertise and experience
or the prognosis is poor. Even if a dentist in consultation without a valid reason for doing so. In addition, the
with the patient decides that the best treatment is a decision is being made not based on an individual
crown, the benet plan can preclude the dentist from patients needs but rather on more generalizable,
rendering the service because they do not think it is the objective information.
right thing to do. Moreover, the licensed dentist consultant making the
Let us go over 1 last example to illustrate the ethical decision to disallow treatment is essentially stating that
dilemma that this disallow adjudication can cause. the service is improper or not necessary. The consultant
Many benet plans have a Least Expensive Alternative dentist is delivering a de facto second opinion. Any sec-
Treatment provision, whereby the plan will pay for an ond opinion regarding treatment, however, should only
amalgam restoration even if a composite restoration is be rendered when the second dentist has at his or her
performed. Hypothetically, if the benet plan decides disposal all the information necessary for an appropriate
that composite restorations do not last as long as treatment decision. The dentist consultant, who is
amalgam restorations and, therefore, disallows compos- totally removed from the patient, does not have the in-
ite restorations, the dentist will be forced to place an formation necessary to make decisions other than benet
amalgam restoration. This is the difference between approval or denial based on the terms of the benet
disallow and denial. If the normal exercise of the Least plan. A third-party dentist consultant certainly does not
Expensive Alternative Treatment clause is used, the have adequate information to deny a patient the oppor-
dentist can still place a composite restoration, accept the tunity to choose treatment regardless of whether a benet
fee for an amalgam restoration from the benet, and bill is paid or not. In such instances in which the dentist
the patient the balance. If the composite restoration is consultant is essentially exercising a level of control over
disallowed, the dentist cannot place a composite resto- treatment that is not justied by the level of information
ration unless he performs the service for free. This and patient interaction, there is a strong argument that
example shows how the plan can exercise control over the licensed dentist consultant is undertaking some
treatment decisions when a procedure is disallowed level of professional and ethical risk.
instead of the usual denial of benets. We are all aware that there are instances when
The American Dental Association Principles of treatment proposed by a dentist may not be appropriate.
Ethics and Code of Professional Conduct (ADA Code) Such instances cannot be defended, and the dental
lays out comprehensive guidance for the learned pro- profession should take an active role in assisting
fession of dentistry.1 The ADA Code puts forward the practitioners to remain within accepted practice param-
basic premise that patient-centered care demands that eters and the ethical considerations incumbent on health
patients values and preferences regarding treatment care professionals. This presents an opportunity for
decisions are an integral part of health care. In Section 1, professional associations and third-party payers to work
Patient Autonomy (self-governance), the ADA Code together to identify, mentor, and correct unethical
states: behavior. However, a system that results in unilateral
interference in the dentist-patient relationship, denying
The dentist has a duty to respect the patients rights to patients their right to involvement in treatment decisions
self-determination and condentiality. and making those decisions without the necessary
This principle expresses the concept that professionals information best evaluated by the patients dentist, is
have a duty to treat the patient according to the patients not an acceptable way to protect patients.
desires, within the bounds of accepted treatment, and to The policy of disallowing claims should be dis-
protect the patients condentiality. Under this principle, continued as inappropriate and potentially unethical.
the dentists primary obligations include involving It does not serve patients well, and it requires dentist
patients in treatment decisions in a meaningful way, with consultants, the licensed dentists who evaluate claims
due consideration being given to the patients needs, for third-party payers, to engage in the questionable
desires and abilities, and safeguarding the patients practice of making treatment decisions without
privacy.1 an adequate informational basis or the necessary
dentist-patient interaction. They should limit their
The result of a third-party payers unilateral treatment decisions to approval or denial of benets to minimize
decision to disallow a procedure is to remove the patient their risk.
entirely from the decision equation and fundamentally Because the original question included the potential
question the integrity of the dentist. If the payer purports ethical issues for the treating dentist, I propose a
to defend the policy by claiming that it is for the sequence of questions that might stimulate further
protection of the patient, then the payer is guilty of thought and discussion.
denying the patient a role in treatment decisions, failing - Does a benet plan, or its licensed dentist consultant,

to acknowledge the importance of such a role and violate any ethical standards by interfering in clinical

408 JADA 148(6) http://jada.ada.org June 2017


SPECIAL COMMUNICATION

decisions between the patient and the dentist by dis- interfere in the dentist-patient relationship and prevent
allowing services? patients from accessing the care agreed on between the
- If yes, is it unethical for a practicing dentist to allow patient and the dentist. n
benet plans to interfere in treatment decisions by dis- http://dx.doi.org/10.1016/j.adaj.2017.03.029
allowing services?
- If yes, are there ethical considerations for a practicing
Dr. Preble is the vice president, Practice Institute, American Dental
dentist in signing a contract that allows or contemplates Association, 211 E. Chicago Ave., Chicago, IL 60611, e-mail prebled@ada.org.
such interference? Address correspondence to Dr. Preble.
I hope this stimulates dialogue in the practicing Disclosure. Dr. Preble did not report any disclosures.
dentist, dentist consultant, and payer communities, with
the aim of developing solutions together that help den- 1. American Dental Association. American Dental Association principles
tists and dental consultants practice ethically. That dia- of ethics and code of professional conduct, with ofcial advisory opinions
revised to November 2016. Available at: http://www.ada.org/w/media/
logue should include the issue of managing consultants ADA/Publications/Files/ADA_Code_of_Ethics_2016.pdf?laen. Accessed
risk created by making decisions that fundamentally April 7, 2017.

JADA 148(6) http://jada.ada.org June 2017 409

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