ADA (and VDA) staff frequently receives calls from dental offices regarding potentially misleading language on explanation of benefits statements sent to patients. Dental and medical plans utilize the EOBs to notify beneficiaries of how an individual claim was processed for payment purposes. The EOB statement provides information such as dates of service, procedure codes, dentist’s fees, dental plan’s allowed amount and total payment.
One area of concern with EOB statements is the lack of consistency of the content between plans. For example, some EOBs include a patient responsibility column and others do not. When a service is downcoded, or an alternate benefit is applied, the EOB should indicate the amount the dentist can bill the patient. Thus the ADA created a model EOB template for consideration by dental plans.
Another area of concern is language that contains misleading and inaccurate statements such as “the treatment was medically unnecessary, experimental or cosmetic in nature.” ADA staff recently received notice of an EOB that read, “Alternative services were available, and should have been utilized.” This statement could potentially interfere with the dentist-patient relationship. In this situation, the plan was immediately contacted by ADA staff to seek alternative language.
EOB language should provide information that clearly delineates the benefit limitations of the plan and any balance due to the dentist by the patient. It should not contain language that may disparage the dentist in any way.
To access the model EOB statement and to view the ADA’s position on EOB statements please visit:
https://success.ada.org/en/practice/dental-benefits/dental-benefit-basics/ada-position-on-explanation-of-benefits