Aetna Payment Changes Alert

We always work hard to provide transparent fees with the most accurate estimates that we can. In that vein, we always want to inform our patients of any trends in insurance reimbursements. We have just been notified by the ADA of an alarming trend with Aetna dental reimbursements and wanted to share.

 Aetna has changed how it determines fees, leading to decreased reimbursements for dentists not in network.

As of Jan. 1, Aetna’s fees are based on the average amount insurers pay for services in a dentist’s geographic area as opposed to the average amount providers charge, as reported by Fair Health. Fair Health is a nonprofit with a database of more than 46 billion healthcare claim records that it uses to estimate average billing and allowed amounts across the country.

This is particularly noticeable when an out-of-network patient receives preventive and diagnostic services. The patient and office expects the services to be covered at 100% with no out-of-pocket expenses given prior history; however, the services are covered at 100% of the plan’s allowed fees for out-of-network providers, likely leaving the patient with a balance due for these services. This is a new alarming trend and we are still seeing how it affects patient reimbursements. ADA’s Center for Dental Benefits, Coding and Quality suggests that we have our patients file a complaint with their employer’s human resources department so that groups that purchase these plans have a better understanding of how their employees are affected by these policies.

For any questions about how this may affect your plan, please email us at so that we can set up a time to call and discuss.

Resources: Versaci M, ADA News accessed May 10, 2024