Constituent Dental Care/Practice Chairperson’s Resource Manual
Originally Published: August 1992
Revised: November 1994
Revised: February 1997
Revised: March 1998
Revised: March 2000
Revised: March 2002
Revised: February 2004
Revised: March 2006
Revised: January 2007
Revised: September 2010
Table of Contents
Insurance, Malpractice 92
AGD Access to Care White Paper 112
This manual is intended to assist you, the Constituent Dental Care/Practice Chairperson, in your role as ombudsman for your constituent’s general dentist members. Yours is a critical role—you are charged with collaborating with the Academy of General Dentistry’s (AGD) Dental Practice Council. You must therefore understand the impact of any issue that might affect the dental profession, the oral or related systemic health of the public, or the general practitioner’s right to practice.
Today, more than ever before, the origins of issues affecting dentistry can have many sources: consumers and consumer action groups; third party payers; national and state legislation and regulation; and various health care organizations. As Constituent Dental Care/Practice Chairperson, you have demonstrated that you are truly interested in and concerned about dental benefit and dental practice issues that are facing the profession. Your responsibilities call for you to share information, initiate inquiries and work with AGD Headquarters staff and/or appropriate Dental Practice Council members relative to dental practice issues that are impacting (or may significantly impact) the practices of AGD members in your constituent.
Specific responsibilities call for you to:
Be familiar with your state or provincial Dental Practice Act.
Keep your constituent informed about local dental practice and dental benefit issues, as well as national issues as summarized in the Dental Practice Council Action Summaries that will be forwarded to you within 30 days after each meeting.
Respond to constituent surveys and/or all other constituent outreach efforts by the Dental Practice Council.
Encourage your constituent editor to regularly publish appropriate articles and relevant dental practice information in your constituent newsletter.
Establish liaison with your state or provincial dental care and legislative committees.
Provide AGD Headquarters with appropriate documentation relative to the details of any dental practice issues occurring on a constituent level, which are impacting (or may significantly impact) the practices of the members of your constituent.
You may also want to become involved in implementing an appropriate constituent dental care project. In many cases, this project should be accomplished in collaboration with your state or provincial dental care and/or legislative committees.
II. Alternative Delivery/Payment Systems
Virtually every allied health care field has had to defend itself against public media coverage of horror stories regarding the skyrocketing cost of care, provider abuse and the insurance industry’s application of various “fix-it” techniques. Dentistry has not been spared this type of negative coverage and, in fact, some would say that dentistry is a victim of this critical publicity because more and more frequently, the cost containment mechanisms used in medical plans are being applied to dental benefits programs with no regard for the most basic differences between the two fields.
The big issue in insurance programs, particularly when it comes to dentistry, in which some procedures are perceived as being wholly elective, is cost containment. Yet insurance companies and insurance plan purchasers frequently fail to realize the most obvious difference between dentistry and medicine—dentistry does not require coverage for catastrophic care. While total medical/dental expenditures may account for an ever-increasing percentage of the Gross National Product, dentistry’s share of the total dollars spent on health care dollars is minuscule.
Yet, as American businesses develop new programs to control health care costs, there is more interest in designing and implementing alternative and less costly systems to deliver health care to the public.
AGD membership surveys have indicated that many AGD members have participated in one or more dental plans, including fee-for-service.
This chapter includes the basic points of various health care delivery systems. The information presented here is intended to familiarize you with some of the plans currently available. It is strongly recommended that any dentist considering participation in any plan conduct a careful and thorough review of the program and its implications. Be aware that voluntary enrollment on the part of the patient can lead to adverse selection, which means that people who need the most care will enroll in greater numbers than those requiring a lower level of care.
Definitions on the following pages that are marked by an asterisk (*) are based on the definitions contained in the Selecting a Dental Benefits Plan brochure published by the American Dental Association’s (ADA) Council on Dental Benefits.
Like other health care professionals, dentists (and dental organizations) are bound by certain government regulations that can seriously restrict their activities or responses to situations perceived as threatening. As an illustration, dentists are frequently approached by third party carriers, which may appear to have great resources, to reduce or discount their fees, alter their reimbursement mechanisms, or change their practice profiles. However, the dental practitioner must be aware that certain reactions, such as price fixing, group boycotts, or even restraint of trade, may result in violation of antitrust regulations.
The penalties for these violations can be quite severe, including substantial fines, imprisonment, and losing one’s license to practice.
Every practicing dentist should have at least a basic understanding of these terms and of the antitrust laws and their enforcement mechanisms. The ADA’s Division of Legal Affairs has issued a publication, The Antitrust Laws in Dentistry, which explains basic antitrust principles and serves as a guide to what actions may or may not be taken when dealing with fees, reimbursements, and third parties. The brochure is available free-of-charge to ADA members.
Signing a Contract:
When a dentist signs a contract to provide services, that contract is a legally enforceable document with responsibilities and obligations that could prove onerous, especially if they were not anticipated. To ensure that the dentist completely understands the terms and conditions of any agreement before entering into a contract, he or she should have the contract reviewed by legal counsel who is qualified to provide advice in this area.
It is not within the scope of this manual to detail every caution to be aware of when signing a contract, but there are many questions that should be answered by the contract. The following questions are for illustrative purposes only and should not be considered to be a complete list.
Is there a hold harmless clause? Do you incur liabilities if you sign it?
If you are not comfortable performing certain procedures, will specialty referral be allowed? If so, under what conditions? Will you or the company choose the specialist? Will you be financially responsible? If not, are there situations where you may become financially responsible?
Do you control and determine treatment?
Under what conditions can you terminate the contract? Are you obligated to treat covered patients after termination? If so, for how long and at what fees?
Will your name be marketed and advertised? How? Do you have prior approval?
What are the terms of payment? If the company does not pay you or stops paying you, are you allowed to collect from the patient?
Are you responsible for charges by another emergency treating dentist?
Will you be subject to utilization review? If you must abide by it, will it compromise your professional judgment?
Who owns and controls the company? What has been its track record?
Does the company have a recoupment policy—that is, can the company do a retrospective review of your records to ask for a refund for procedures performed deemed unnecessary?
Dentists considering participation in an alternative delivery/payment system may wish to contact AGD HQ at BenefitsAdvocate@agd.org for the AGD’s contract analysis service, which is free to members. After receiving the analysis, dentists should share and/or review this information with their personal attorney and/or financial advisor to determine whether the new program will fit into their current dental practice. Additionally, the ADA also offers a similar program to members for a nominal fee. You may contact the ADA Contract Analysis Service at