Bracken Killpack
Executive Director, WSDA

Dental benefits billing can be frustrating for dentists and their teams. Payors routinely justify their processing policies in the name of administrative efficiency or as mitigation of “waste, fraud, or abuse.” Clinicians often see those policies as an extra administrative hurdle or a strategy to contain payor costs since not all offices will challenge a denied claim.

Dental offices frequently ask what WSDA is doing to address dental benefits billing issues that negatively impact patient care. Today, we are excited to share an example of what we are doing and how our robust advocacy efforts help dental offices and patients not only in Washington but across the nation.

One policy that has routinely come up in our discussions has been a national Delta Dental Plans Association (DDPA) processing policy related to bundling panoramic radiographs (D0330) into a full mouth series (D0210). Currently (until January 2024), the DDPA has two germane policies:

Individually listed intraoral radiographic images by the same dentist/dental office are considered a complete series if the fee for individual radiographic images equals or exceeds the fee for a complete series done on the same date of service. Any fee in excess of the fee for a full mouth series (D0210) is not billable to the patient. (Emphasis added)

And:

A panoramic radiographic image, with or without supplemental radiographic images (such as periapicals, bitewings and/or occlusal), is considered a complete series for the purpose of frequency limitations and any fee in excess of the fee allowed for D0210 is not billable to the patient.

Following the lawsuit between WSDA and Delta Dental of Washington (DDWA), a Memorandum of Understanding was written, committing the two organizations to work together on issues of significance to Washington’s dental community. The Policies and Plans Joint Workgroup was established in November 2021 with representatives from both organizations to explore Delta Dental processing policies (both DDWA-specific and national) among other projects. One of the workgroup’s priorities is to identify, discuss and modify processing policies that can negatively impact patient health. The workgroup concluded that the aforementioned policies have a negative impact on patients. Based upon the workgroup’s conclusion, DDWA submitted a policy change recommendation to their national association.

That recommendation is based on the belief that supplemental radiographic images taken in the same visit as a panoramic radiograph should be billable to the patient. Bitewing and periapical radiographs are usually prescribed to help diagnose oral disease, while panoramic radiographs are typically prescribed to monitor dentofacial growth and development. The fact that, under the current policy, both D0330 and D0210 would be reimbursed if they were performed on the same patient on different days, but not if performed on the same day, demonstrates the lack of clinical foundation for the existing policy.

The committee overseeing DDPA policies reviewed this change recommendation two different times and, in April 2023, voted unanimously to change it. Starting in January 2024, panoramic radiographs (D0330)will be exempt from the list of radiographs that get bundled and converted to a full mouth series if the combination of the total allowed fees exceeded the fee for a full mouth series (D0210).

Quality diagnostic information is fundamental to making appropriate treatment decisions, and billing for different types of images to help diagnose diverse conditions should not be limited by Delta Dental policy. The DDPA now agrees.

Advocacy for WSDA members takes many different forms. Sometimes we are visibly advocating for or against legislation or pending regulation. Other times, our work includes less visible actions like monthly meetings focused on DDPA processing policies. Regardless of the form our advocacy takes, we are doggedly working for you.

Thanks to everyone in the Policy and Plans Workgroup for getting this important change across the finish line. Getting this national policy change required collaboration between DDWA and WSDA. WSDA and DDWA will not always agree on substantive issues and there will continue to be times when we are on opposite sides. However, this example demonstrates what can be done when we work together.