Chapter 14: Patient Dental Benefits

Transcription

1 Chapter 14: Patient Dental Benefits The dentist-patient relationship is most important; the thirdparty payer merely provides a source of payment assistance. Dental Benefit Plans Communication rests at the core of any good dentist/patient/third-party payer relationship and is more effective when everyone understands their roles. The dentist uses his or her clinical judgment to determine the best treatment for the patient and establishes a fee for each service rendered. The patient is expected to be at the office to receive services that are scheduled according to the treatment plan, and has financial responsibility for payment. Payments may be made directly to the dentist, or with assistance from the third-party payer, if any. The thirdparty payer, when there is one, determines the payment it will make, based on the services reported on a claim and the coverage provisions (e.g., limitations and exclusions) of the dental benefit plan purchased by the patient s employer. The third-party payer does not, however, determine the treatment. If a dentist has signed a participating provider agreement with a third-party payer, that contract may place a limit on the dentist s fees for services to patients with coverage from that third-party payer. Additionally, this provider contract may preclude balance billing of the patient for services. In some cases, the participating provider agreement may preclude billing the patient at all for certain services in particular situations. Dental benefit plans can be an asset to your practice. Both your cash flow and level of patient satisfaction may grow with good relations between your patients and third-party payers. Patient understanding The dentist-patient relationship is most important; the third-party payer merely provides a source of payment assistance. Thus, the dentist is directly responsible to the patient for professional services; the patient is directly responsible to the dentist for payment unless the benefits are directly assigned to the dentist. All patients should be treated impartially, receiving equivalent fee and treatment consideration, regardless of their insurance status. This is not to suggest that dentists must charge all patients the lowest fee set by a participating provider agreement. When discussing treatment plans and payment practices with patients, share your experiences regarding dental benefit plans in general that you have experienced. Let your patient know that the benefits may change over time. Summaries should include: maximum annual and lifetime benefits; deductibles; predetermination limits; co-insurance factors; reimbursement amounts available from the payer (sometimes termed UCR, usual, customary and reasonable) percentages or scheduled benefits; toll-free telephone numbers; persons to contact in the employer s and third party payer s office; coverage of preventive services; and orthodontic coverage. Your primary concern is the dental care needs of the patient; that point is the one you should emphasize. Stress that a third-party payer will pay only an amount determined by appropriate members of its staff, in accordance with the contract. Paperwork A common complaint in the dental profession concerns the paperwork involved in processing insurance forms. For ease of claim form completion, establish efficient office procedures to handle benefit program paperwork. Keep the dental benefit file separate from the patient record files, so the status of any claim can be readily determined. Check these files frequently for claims requiring attention. Mark patient files with a colored sticker if the patients are covered by a dental benefit program. This allows the paperwork to be initiated by your staff in a timely fashion. Summarize your policies about accepting assignment in a written statement. Use it to guide your discussion with patients; provide copies during case presentations. One version of such a policy statement that can be adapted to suit your practice is found on page

2 Predetermination Depending on the benefit program, you may need to file a predetermination form. Submission of a treatment plan for procedures that will cost $150-$250 or more is generally required. This allows a predetermination of the amount of benefits payable upon completion of the treatment. Keep in mind that a predetermination of benefits is not a guarantee of payment. Many offices use the ADA-approved claim form to file for predetermination. (See sample on page 112.) Print your name, address and I.D. license numbers on this form. Please note that provider I.D.s may vary by payer until National Provider Identifier (NPI) is in place. NPI is the nationwide standard way to identify dentists and other health care providers, whose use is required. The ADA claim form is available in a variety of ways (e.g. NCR, continuous form) to fit your needs. All ADA claim forms are available through the ADA Catalog, or online at Submit the original to the carrier and keep copies in both your insurance file and the patient file. Advise the patient when determination of benefits has been received from the carrier and file patient s insurance claim record under cases in treatment. Keep a folder of pending insurance pre-determinations for follow-up purposes. Claim Submission When treatment is complete, submit the claim to the third-party payer. A copy of the claim should also be kept in your payment pending file. This duplicate should contain all pertinent information so that, if the original is lost, the facts are easily accessible. At the end of this chapter you will find a number of materials that will help you in handling dental benefit claims, including sample letters to patients, the ADA-approved claim form, and the Association s Guidelines on the Use of Images in Dental Care Programs. For information regarding electronic submission of claims, refer to Chapter 12 Bookkeeping, Taxes and Computers. Finally, if a dentist runs into a dispute with an insurance company, one possible option available to settle the dispute is to initiate peer review through your state dental society, assuming that this option is offered. There are several state dental societies that provide peer reviews between dentists and insurance carriers and this can be an effective tool to help dental offices resolve concerns with carriers. Please check with your constituent dental society to determine is such assistance is provided. Third-party contracts: should you sign? Your decision to join a third-party system (DHMO, PPO, IPA, closed panel, etc.) is a professional one that can dramatically affect your practice. The ADA does not encourage dentists to make any extended business decisions, including whether and how to participate in such plans, without diligent investigation and weighing the pros and cons. As with any business decision, it is prudent to begin with consideration of the effects the proposal will have on the business aspects of the practice and whether it can advance the practice s long-range goals. If the proposal is attractive financially, the legal and financial aspects of the proposal should be carefully considered to be certain that there are adequate protections for the dentist. At this point, your personal financial and/or legal counsel can provide valuable professional advice and assist you in negotiating terms that are important to you. The ADA offers a contract analysis service that analyzes legal aspects of proposed written contracts between individual dentists and third-party dental benefit organizations, and makes the analysis available to members as a matter of the highest priority. Your decision to join a third-party system is a professional one that can dramatically affect your practice. 107

3 Most indemnity plans reimburse patients based on a Usual, Customary and Reasonable (UCR) system. This contract analysis service does not provide individualized legal advice for members, and in no way takes the place of the member s own attorney. Nor does it provide practice advice. Contact your state dental society or the American Dental Association contract analysis service for more information. For more information regarding specific plans, please contact the National Committee on Quality Assurance (NCQA) at Another good resource for dentists who sign up for numerous plans is the Coalition for Affordable Quality Healthcare (CAQH). Contact them at Types of Dental Benefit Plans There are several different types of dental benefit plans in the market today. The seven most common types of plans are discussed below. Direct Reimbursement Direct Reimbursement (DR ) is a self-funded dental benefits plan that reimburses patients according to dollars spent on dental care and not the type of treatment received. It allows the patient complete freedom to choose any dentist. Instead of paying monthly insurance premiums, even for employees who don t use the dentist, employers pay a percentage of actual treatments received. Moreover, employers are removed from the potential responsibility of influencing treatment decisions due to plan selection or sponsorship. DR is the ADA s preferred method of financing dental treatment. The design of the DR plan is selected by the employer to fit the employer s budget, and can therefore vary widely among companies. For example, one plan may reimburse 100% of the first $200 of dental expenses, 80% of the next $250 and 50% of the next $2,200, resulting in a total annual maximum benefit of $1,500 per covered individual. Another company may reimburse 50% of the next $3,000 of dental expenses, resulting in a total annual maximum benefit of $1,500 per covered individual. The totals can be individual or family maximums. A DR plan may also permit employees to pay their share of their dental expenses on a beforetax basis by establishing dental flex accounts. Flex accounts are funded by employees with pre-tax paycheck withholding, and can be used to pay dental expenses that are not covered by the DR plan design. In addition to the employee s tax savings, the employer benefits because the amounts withheld from the employees paychecks are not subject to FICA taxes. Flex accounts must comply with IRS regulations to insure that the payments qualify for pre-tax treatment. The ADA, as well as state dental societies, brokers and benefits consultants can assist a company in estimating how different designs will affect costs. To utilize this service, call the ADA at extension Indemnity An indemnity plan is a fully insured or selfinsured non-network dental plan that reimburses the member or dentist at a certain percentage of charges for services rendered, often after a deductible has been satisfied. Indemnity plans typically place no restrictions on which dentist a member may visit. Indemnity plans are also referred to as fee-for-service plans. Most indemnity plans reimburse patients based on a Usual, Customary and Reasonable (UCR) system. In other words, UCR plans pay an established percentage of the dentist s fee or the plan administrator s reasonable or customary fee limit, whichever is less. The limits are the result of a contract between the plan purchaser and the third-party payer. Although these limits are called customary, they may or may not accurately reflect the fees that area dentists charge. There is wide fluctuation as to how plans determine the customary fee level. A UCR element is not exclusive to indemnity plan types. 108

4 Preferred Provider Organization Preferred Provider Organization (PPO) programs are plans under which patients select a dentist from a network or list of providers who have agreed, by contract, to discount their fees. In PPOs that allow patients to receive treatment from a non-participating dentist, patients who choose a non-participating dentist are usually required to pay higher deductibles and/or copayments. PPOs can be fully insured or selfinsured. PPOs are usually less expensive than comparable indemnity plans and are regulated under the appropriate insurance statutes in the company s state of domicile and operation. Dental Health Maintenance Organization/Capitation Plan Dental Health Maintenance Organization (DHMO) or capitation plans pay contracted dentists a fixed amount (usually on a monthly basis) per enrolled family or individual, regardless of utilization. In return, the dentists agree to provide specific types of treatment to the patient. The patient may be required to pay a co-payment. Theoretically, the DHMO rewards dentists who keep patients in good health, thereby keeping costs low. DHMO models typically offer the least expensive dental plans. Discount/Referral Options Discount (referral) plans are arrangements in which employers direct employees to a limited number of providers who have agreed to discount their normal fees in exchange for the expectation of a larger patient pool. Patients pay the discounted fee directly to the dentist. There is no third party reimbursement to the patient or to the provider. A third-party marketer will package and sell a discount program for a fee, in order to cover administrative costs and profits. Point of Service Options Point of Service (POS) plans are health plans that allow the member to choose to receive a service from a participating or nonparticipating provider, with different benefit levels associated with the use of participating providers. Table of Allowance Table of allowance (sometimes called schedule of allowance ) indemnity programs determine a list of covered services with an assigned dollar amount. That dollar amount represents just how much the plan will pay for those services that are covered. Most often, it does not represent the dentist s full charge for those services. The patient usually pays the difference. Code On Dental Procedures and Nomenclature The ADA Code on Dental Procedures and Nomenclature (CODE) is used to record the services you provide to a patient and to report dental treatment on claims submitted to thirdparty payers. The current version of the Code is effective January 1, 2007 through December 31, 2008 and is published by the ADA in the manual titled CDT 2007/2008. This manual includes other information that can assist in preparing claims. Copies of CDT 2007/2008 can be ordered from the ADA Catalog at or online at The Code lists dental procedures by category of services (e.g. Diagnostic, Restorative). Each code number includes a definition (nomenclature) plus additional explanatory information (description). 109

5 Sample Letter to the Patient (Where dentist has NO CONTRACT with the insurance company) Dear Patient: As a courtesy, I file insurance claims on behalf of my patients for dental services performed in my office. It is important to remember that as your dentist I can only file claims on your behalf. The benefits belong to you, and it is up to you to ensure that you are receiving appropriate reimbursement under the terms of your plan. Employers purchase dental insurance for their employees to supplement the cost of care. Unlike medical insurance, most dental benefits do not cover the full cost of care. In fact, according to recent statistics from the U.S. Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS), private dental insurance paid only 48% of the cost for dental care. You will be responsible for paying my office for any services provided that are not covered by your insurance, and for any fees that are above the amount payable by your benefits program. There may be times when claims for what appear to be clearly covered procedures are denied. Should this happen, the information outlined below may be helpful to you. 1. Since you are the insured individual and I do not have a contractual agreement with your insurance carrier, you are responsible for appealing the claim and paying any outstanding amount that is not covered by your dental benefits plan. 2. As your dentist, I will provide you with an accurate statement of services rendered or treatment proposed and will work with you toward a resolution. 3. In cases where conflicts arise over reimbursement, denial of claims or proposed treatment, or other administrative problems for a service that appears to be covered by your dental benefits plan I recommend that you involve your employer (or other plan purchaser) in order to find an appropriate solution. 4. Exhaust all reasonable avenues for resolution with the insurer. This means using all levels of appeal. Make sure that all supporting documentation is included with the claim. File a complaint with your benefits manager. Since your employer purchases insurance on your behalf, it will want to know if you are having problems obtaining the available coverage. If the claim cannot be resolved through the appeals process, and if the plan is state regulated, contact the State Insurance Commissioner and file a complaint that clearly outlines your case. If the plan is self-funded, it is regulated by the U.S. Department of Labor. Complaints can be filed with the U.S. Department of Labor, Pension and Welfare Benefits Administration, 200 Constitution Avenue, N.W., Washington, D.C., You may also wish to contact the [Insert name and phone number of your State Dental Association]. I appreciate the opportunity to be your dentist. Please feel free to call me if I can be of assistance to you. Very Truly Yours, Dentist s Name 110

6 Sample Attachment (Where dentist has NO CONTRACT with the insurance company) Please note the language set forth below can be combined with the language on the previous page, or be used in a separate letter to the patient. You may also find the following suggestions helpful in understanding your dental benefit plan and ensuring appropriate coverage: Plan Program. Read your dental plan benefits booklet carefully so you fully understand the extent of your dental coverage. Dental insurance, unlike medical insurance, rarely covers the total cost of treatment. It is critical that you understand the treatments or procedures your plan includes, excludes or restricts. If you are unsure of any benefits to which you are entitled, consult your benefits manager or plan administrator. Copayments/Deductibles. Ask your plan administrator or benefits manager what you are responsible for paying when you use your dental benefits (e.g., deductibles, co-payments). Preauthorization. Some dental benefit plans require that the treatment plan be reviewed to determine whether the plan provides reimbursement for the procedures before treatment starts. This will help you determine which services are your financial responsibility. Before using your dental benefits, determine which services, if any, have to be preauthorized/pre-determined by the carrier. Statement of Services. To assist in filing your own claims, obtain a complete statement of services from our office which thoroughly explains the services provided. Authorization of Benefits and Assignments of Benefits. If I am going to file claims on your behalf, please be sure to sign the authorization of benefits statement on the ADA claim form. This allows me to receive reimbursement directly from the insurance carrier on your behalf. However, I do reserve the right not to accept the assignment of benefits (i.e., payment directly from your insurance plan). Sometimes the benefit plan provided by your employer only covers a portion of the cost of your treatment. Under these circumstances, I may not be willing to accept any assignment of benefits that would preclude me from receiving my full fee. If you are not entitled to any benefits under your insurance program, you are still responsible for paying for any services rendered. Treatment Plan. If you are uncertain about any of the procedures or costs associated with the procedures, consult our office. It is better for us to discuss your concerns prior to rather than after the service has been performed. We are accustomed to answering questions from patients and you should feel free to inquire about any concerns you may have. PLEASE NOTE: THE SAMPLE LETTER AND ATTACHMENT ARE OFFERED FOR YOUR INFORMATION AND DO NOT CONSTITUTE LEGAL ADVICE. DENTISTS MUST CONSULT WITH THEIR PRIVATE ATTORNEYS FOR SUCH ADVICE. 111

7 112 Dental Claim Form

8 Dental Claim Form Completion Instructions 113

9 Guidelines on the use of Images in Dental Benefit Programs The American Dental Association s recommendations on selection criteria for images state that diagnostic imagery should be used only after clinical examination, review of the patient s history, and consideration of the dental and general health needs of the patient. The type, frequency and extent of diagnostic images necessary for each individual patient will be provided in accordance with the dentist s professional judgment. The Association believes that the following guidelines should be applied in the use of images in dental benefits plans: 1. Images should be taken only for clinical reasons as determined by the patient s dentist. Clinical images may be used as part of a system for determining those benefits to which the patient is entitled under the terms of a contract. However, third-party payers should not request that images be taken for administrative purposes and dentists should not comply with such requests. 2. When a dentist determines that it is appropriate to comply with a third-party payer s request for images, a duplicate set should be submitted and the originals retained by the dentist. 3. There are many instances in which a determination of benefits cannot be made solely on the basis of images and it is improper for third-party payers to deny benefits or make determinations about treatment that could not ordinarily be made without proper examination of the patient. 4. Third-party payers shall not use images to infringe upon the professional judgment of the treating dentist, or to interfere in any way with the dentist-patient relationship. All questions of interpretation of images must be reviewed by a dentist consultant. 5. Patients should be exposed to radiation only when clinically necessary, as determined by the treating dentist. Postoperative images should be required only as part of dental treatment. 6. It is important that images be correctly mounted and are of diagnostic quality. 7. Third-party payers should protect the confidentiality of all records, including images, which are submitted to them by dental offices. Al! mages submitted to third-party payers should be returned to the treating dentist within fifteen (15) working days. 8. Images held by parties, other than the treating dentist should not be transmitted to any agency or entity without written consent f the dentist or patient. 9. Where a claim or predetermination request indicates that images are enclosed, he third-party payer should immediately notify the submitting dentist s office if the images are missing. 10. A patient s predetermination request or claim should not be prejudiced by the third-party payer s loss or misplacement of images. 11. Images are an integral part of the dentist s clinical records and, as such, should be considered the property of the dentist where consistent with state law. Because it is necessary for a dentist to maintain accurate and complete records, third-party payers should accept copies of images in lieu of originals. 12. Any additional costs incurred by the dentist in copying images and clinical records for claims determination should be reimbursed by the third-party payer or the patient. Source: ADA Current Policies, Guidelines on the Use of Images in Dental Benefit Programs (1995:617). 114