Aetna resolves Medicare claims-processing error after ADA push

Association reminds dentists to be vigilant when reviewing explanations of benefits

Thanks to efforts by the American Dental Association, Aetna has resolved a processing issue that affected reimbursements for out-of-network Medicare Advantage dental claims.

A system configuration error had resulted in some dental claims being adjudicated based on Medicare medical rules rather than the rules typically applied to dental benefits, according to information provided by Aetna to the ADA.

Aetna has since reported it is implementing system changes to address the issue and its claims team will adjudicate affected claims correctly while the updates are completed. The team will also review previously impacted claims to determine whether reprocessing and correction are needed.

“We appreciate Aetna’s attention to this matter and its action to identify and correct the claims-processing error,” said Shelley Olson, D.D.S., chair of the ADA Council on Dental Benefit Programs. “The ADA’s advocacy helped elevate dentists’ concerns and will continue to support more accurate claims adjudication and greater accountability when benefit-processing issues arise.”

The issue first came to the ADA’s attention after dentists reported receiving explanations of benefits that appeared to restrict balance billing for out-of-network Medicare Advantage dental services. While Aetna initially characterized individual claim errors as isolated mistakes, additional reports seemed to suggest a broader pattern. The ADA raised concerns with the payer and sought a more comprehensive review of the issue, requesting clarification on how claims were being processed and whether affected claims would be corrected.

During the months-long investigation, Aetna determined that about 55,000 claims may have been impacted, representing roughly 8% of the out-of-network claims included in the review.

The ADA will continue to monitor this issue and advises member dentists who believe they may have been impacted to contact Aetna about potentially reprocessing the affected claims.

“This situation underscores the importance of dentists and their teams remaining vigilant when reviewing explanations of benefits and understanding the rights and laws that govern dental benefits in their state,” said Liz Papineau, D.D.S., policy chair of the ADA Council on Dental Benefit Programs. “The better understanding the entire dental team has of their rights and applicable laws, the easier it is to identify claims that may not have been adjudicated correctly. When something does not appear to be correct, dentists and team members should not hesitate to ask questions, seek clarification from the payer and use available resources to help ensure claims are processed in a way consistent with applicable benefit rules and state requirements.”

One of those resources is the ADA Third Party Payer Concierge, which offers complimentary assistance to ADA member dentists on dental benefit issues. Members can reach the concierge by email at dentalbenefits@ada.org.