Dear ADA: Exclusivity clauses

Dental insurance issues are often rated as one of dentists’ chief challenges.

In response to an ADA Health Policy Institute poll in late 2024, more than half of dentists reported that one of their top concerns looking ahead to 2025 was related to insurance, including low insurance reimbursement rates, denied or delayed payments, and issues related to Medicaid and Medicare.

This new ADA News series aims to address some of those challenges. “Dear ADA” will feature answers to common insurance-related questions the American Dental Association receives from members to help provide clarity and direct members to additional resources.

The answer to this month’s question is provided by Shelley Olson, D.D.S., chair of the ADA Council on Dental Benefit Programs.

Dear ADA: I am increasingly concerned about exclusivity clauses that some insurance carriers are inserting into provider agreements. These clauses limit my ability to participate in multiple networks and restrict patient access to care by reducing their choice of providers. Why isn’t the ADA taking a more active role in addressing the issue of exclusivity clauses in dental insurance contracts? Many of us feel these provisions are anti-competitive, disadvantage both providers and patients, and ultimately interfere with our ability to provide care.

Dr. Olson: Thank you for sharing your concerns about exclusivity clauses in insurance contracts. You’re not alone. This is something we hear from members regularly, and we know how frustrating and disruptive these provisions can be for you and your patients.

Some dentists choose to join exclusive programs, often because they offer the promise of an enhanced fee schedule. For certain practices, that can provide short-term financial stability. However, these benefits must be weighed against the longer-term consequences of reduced patient choice, limited flexibility and shrinking referral options.

Here are some of the main ways the ADA believes exclusivity clauses affect care:

• Limits on your practice: They can prevent dentists from joining multiple networks, which limits your ability to grow and serve patients under different plans.

• Fewer choices for patients: Patients may not be able to see their preferred dentist if their plan is excluded. That can break continuity of care.

• Access problems in smaller communities: In areas with fewer providers, exclusivity makes networks even narrower, which forces patients to travel farther.

• Higher costs for patients: If they must go out of network, they face bigger co-pays, deductibles or uncovered bills.

• Delayed or skipped care: Barriers like travel, higher costs or lack of access often mean patients put off treatment.

• Erosion of trust: Patients may feel like insurers, not clinical judgment, are dictating who they can see.

We’ve seen these issues firsthand. Members are asking the same questions you are: “Isn’t this a monopoly? Can the Association take legal action? What can I do right now to advocate for myself and my patients?” We know these issues keep dentists up at night; they keep us up at night, too.

The ADA is actively engaging in advocacy, legal action and education to safeguard dentists and patients from potentially harmful insurance practices. We also provide tools you can use now, like the ADA’s contract analysis service, Third Party Payer Concierge, dental insurance guides and even patient letter templates if you need to exit a network.

When the issue of network exclusivity arose in Missouri, the Missouri Dental Association noted in its official magazine that “offering providers a choice of networks to which they can belong — and specifically outlining that one network choice is to be a Premier Exclusive dentist by only participating in Delta Dental of Missouri and not contracting with other providers — does not appear to be per se illegal under the antitrust laws. Dentists have options; dentists have the right to make a decision to be in the network or out of the network…”

Providers must have a clear, informed and affirmative choice in deciding where and how they participate in networks. Participation should be based on an explicit opt-in process — not assumed, transferred or implied. The integrity of provider contracting depends on transparency, mutual consent and a shared understanding of terms. The flip side of network exclusivity is network leasing, in which provider contracts are resold or shared across multiple payer networks without the provider's direct authorization. Such practices erode trust, create confusion for patients, and strip providers of their right to determine where their professional services are offered and at what rates.

The bottom line: Exclusivity clauses are detrimental to dentists, patients and access to care. We’re tackling this issue on multiple fronts, including in state legislatures and by equipping members with resources to make informed decisions for their practices at ADA.org/dentalinsurance.

Please know you’re not alone in this fight. The ADA and your state association are in it with you, and we’ll keep pushing for a system that’s more fair, transparent and focused on patient care.