ADA Contract Analysis Service can help members with provider contract issues
When a dentist decides to join a dental/preferred provider organization, dental health maintenance organization or discount dental plan, he or she enters into a contractual relationship with the dental insurance carrier. Although insurance carrier contracts vary widely, most have key common provisions and related documents.
A clear understanding of contractual obligations is a vital part of the relationship between dentist and carrier. The ADA Legal Division started its Contract Analysis Service in 1987 to provide assistance to member dentists who need help analyzing the terms of provider agreements. Since then, the service has analyzed more than 3,900 dental provider contracts. The CAS analyzes dental provider contracts, business associate agreements, dental management service organizations contracts and contracts that offer dental school students scholarships or loans in exchange for a commitment for future employment.
CAS primarily works in five areas:
- providing plain language;
- informational analyses of dental provider contracts submitted to the ADA;
- monitoring dental benefit organizations’ activities on dentist related contracting issues;
- disseminating information to individual members and constituent dental societies through literature prepared by the service;
- presenting seminars and workshops concerning legal implications of dental provider contracts.
To maximize the service’s efficiency, member dentists are encouraged to submit contract analysis requests through their state or local dental societies. There is no charge when contracts are submitted for analysis in this way. Individual members submitting requests directly to the service pay $50 for an analysis of a provider contract.
The service responds frequently to telephone inquiries from members about dental provider contracting issues and offers programs and written information on such matters. The CAS developed member resource entitled, “What Every Dentist Should Know Before Signing a Dental Provider Contract is available online at ADA.org. Go to www.ada.org/members/law/issues_business.asp#cas or contact the ADA toll-free, Ext. 7479.
The most common contract provisions found in a participating dentist agreement include:
- Minimum participation criteria
- Arbitration
- Patient eligibility
- Treatment in progress
- Quality management and utilization management programs
- Compensation (fee levels/schedules)
- Affiliated carriers
- Continuity of care
- Risk management
- Referrals to specialists
- Termination
- Plan insolvency
- Automatic contract renewal
Reimbursement guidelines, including required treatment documentation, are usually contained in separate documents such as the provider reference manual or frequently asked questions. The participating dentist reference manuals and related documents are usually incorporated into contracts by reference, which means that they become part of the contract. The CAS advises dentists to carefully review any and all applicable documents included in the contract prior to its execution.