ADA calls for greater oversight of dental insurance markets

Association raises concerns about insurer concentration, contracting practices, Medicare Advantage dental benefits 

The ADA is urging Congress to strengthen oversight of dental insurance markets while ensuring that policies aimed at improving competition and preventing fraud do not create unnecessary burdens for independent dental practices. 

In comments submitted to the House Judiciary Subcommittee on the Administrative State, Regulatory Reform, and Antitrust, the Association outlined several dental-related issues ahead of the Subcommittee’s Sept. 14 field hearing, “Examining Healthcare Markets: Fraud and Competition.” The hearing addressed health care competition, insurance practices and other market issues. 

The ADA said dental insurance markets should be included in broader discussions of health care competition, noting that insurer market structure and practices can affect patient access, provider choice and dental practices. 

“The ADA supports vigorous, evidence-based enforcement against fraud and anticompetitive conduct,” the Association wrote. “At the same time, policy responses should be targeted to the source of the problem and should not impose broad new burdens on independent dental practices that are unlikely to improve program integrity or competition.” 

One area highlighted by the Association is concentration in the stand-alone dental insurance market. According to the letter, a U.S. Government Accountability Office analysis found that the three largest stand-alone dental insurers collectively accounted for from 38% to 97% of the group market across states, with their combined share reaching at least 80% in 11 states. The ADA urged continued federal examination of mergers and acquisitions, vertical integration, network design, patient steering and contracting practices. 

The Association also raised concerns about network leasing. According to the letter, shared-network arrangements are not inherently harmful, but extending a dentist’s contracted rates to additional entities without clear disclosure and affirmative consent can make it difficult for dentists and patients to understand which network and fee terms apply. 

The ADA said it supports advance notice of material contract and fee-schedule changes as well as a dentist’s affirmative opt-in to new network arrangements. 

The letter also addressed the Employee Retirement Income Security Act, or ERISA. According to the ADA, carriers and third-party administrators have at times asserted ERISA preemption to avoid state dental insurance protections that apply to fully insured plans. The Association said it supports preserving ERISA’s core role while clarifying that state laws regulating the provision and payment of dental care are not displaced simply because a carrier administers a self-funded plan. 

Medicare Advantage supplemental dental benefits were another focus. According to the letter, 52% of Medicare Advantage beneficiaries selected their plan based on the inclusion of a supplemental dental benefit. The ADA called for improved dental-specific reporting on benefit design, utilization, network adequacy, claims payment and spending. 

The Association also urged greater automation of dental administrative transactions in Medicare Advantage, including standardized electronic eligibility and benefit verification. According to the letter, manual verification of varying plan designs creates administrative burdens for dental practices. 

On fraud, waste and abuse, the ADA said fraud-prevention efforts should be targeted and evidence-based. The Association specifically addressed the use of artificial intelligence and automated claims reviews. 

“Payment suspensions, artificial-intelligence tools and automated claims reviews should include appropriate validation, transparency, appeal rights and human review,” the ADA wrote. “Insurers should not use AI as the sole basis for claim denials or prior authorization decisions.” 

The ADA also cautioned against applying policies designed to address consolidation or provider market power in ways that could burden smaller practices. 

“Independent dental practices are generally small businesses and should not be conflated with large, consolidated health systems when Congress considers remedies aimed at provider market power,” the Association wrote. 

The Association concluded by urging the subcommittee to include dental markets in its examination of health care competition and insurance practices and to pursue transparency and fraud-prevention policies without creating unnecessary barriers to patient care.