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Third-party payer arrangements
Dental Reimbursement Third-party payer arrangements Background.—Having dental insurance is related to a greater likelihood that an individual will see a dentist, will take children to see the dentist, will seek restorative care, and will enjoy better overall health. Thus, dental insurance provides clear benefits to patients, but practitioners are often frustrated by the perception that third-party payers are providing insufficient reimbursement rates and too many claim denials. Whether these perceptions are accurate or not was analyzed. Coverage and Participation.—Sixty-four percent of the US population is currently covered by dental insurance plans, with three-quarters of these being private plans, usually provided through employers or groups. Public programs such as Medicaid provide the remainder. Eighty-two of the 100 dental insurance providers operating in the United States are members of the National Association of Dental Plans (NADP). Nearly 80% are preferred provider organizations (PPOs). The NADP conducts an annual survey to understand dental provider participation in provider networks. The 2014 report indicates that more than 95% of professionally active dentists participate in at least one network. The average dentist accepts 5.7 PPO networks. Despite these high rates of participation, some industry observers and practitioners believe reimbursement rates have fallen, which has had negative influences on practice profitability. In addition, there can be limitations on which laboratories can be used because of the reimbursement levels. In addition, some claims are denied, requiring extra steps to obtain any payment. Claims related to cone-beam computed tomography (CBCT) are frustrating because they are often denied even though the scans prove extremely useful. Experts recognize that billing is complicated by the requirement that the facility be registered with the state, and each state has different regulations, but counter that being registered allows CBCT claims of many types to be reimbursed. Overhead costs that are not covered create another problem area facing many dentists. Reimbursement rates can adversely affect the business of dentistry. To counter the problem, offices are forced to create practices that are well-run businesses—and that skill is not taught in dental schools. Dentists must develop highly efficient systems, allowing them to increase their volume comfortably, efficiently, and without creating extreme stress to counteract the effect of low reimbursement rates.
Relevant Factors.—Factors that contribute to the problem of reimbursement include those related to the insurance industry and those involving Medicaid expansion. With respect to the insurance factors, a few PPOs have schedules of changes that reimburse a set amount per procedure. Most, however, establish a level of reimbursement that does not change from year to year. What changes constantly, however, are the data about the usual charges that form the basis for reimbursement. The data are collected by FAIR Health, an independent not-for-profit corporation designed to bring transparency to the costs of health and the health insurance industry. It maintains databases about dental charges across the country. Dentists submit information about what they charge (not what they are being reimbursed) on claims, and the information is passed along to FAIR Health. Carriers get aggregated FAIR Health data several times a year and insurers adjust the underlying rate for procedures based on the data. Generally the result is a slight change in rate. An analysis of the charges for pediatric dental services in all 50 states indicated that, after adjustment for inflation, the average charges in 31 states increased more than the inflation rate, but those in 19 states did not. In most cases, private dental insurance reimbursement has been keeping pace with inflation. However, the fees paid to dentists have not increased much and are often remaining stagnant at earlier levels. Insurance companies previously did not cover some procedures, such as implants and tooth whitening, but currently companies are saying that everything is covered but some of the coverage is zero. When this is translated into practice, insurers essentially set what dentists can charge patients for non-covered services. Dental associations are working to persuade legislatures to pass laws prohibiting this behavior, but the problem is being fought one state at a time. Assignment of insurance benefits is also a battleground for problems. Traditionally, if a practice does not participate in the plan, the benefit check is sent to the patient and the dentist is responsible for getting the money from him or her. Recently laws in a few states have allowed patients to assign their insurance benefits to dentists who aren’t in their dental plans. This approach makes patients happier, but often state dental associations don’t understand that they must pass such legislation before this can be done.
Volume 61
Issue 5
2016
233
The Affordable Care Act (ACA) has changed dental benefits by encouraging the expansion of Medicaid eligibility and increasing enrollment. The growth in the Medicaid market is like a tsunami. Medicaid reimbursement is historically low, but an increase in volume should be an excellent way to increase the total dollars a practice brings in. Some insurance companies have proposed that Medicaid reimbursements should be outcome-based rather than disease-oriented. In this way, dentists who perform better would be rewarded with higher reimbursement fees and direct referrals from call centers. Other rewards for performance include waiving prior authorizations based on the quality of the dentistry delivered. The quality of dentistry can also include having evening, weekend, or emergency hours available, which is a good thing for patients. Proposed Changes.—Plans are being proposed to help control costs, which would minimize the effect of low reimbursement rates. One trend is to create ‘‘narrow networks’’ of dental care providers, hospitals, and physicians who have demonstrated that they can provide care in a cost-effective manner with outcomes similar to those who charge more. Having a ‘‘narrow network’’ choice to offer clients may actually increase the level of benefits available to members while lowering employers’ premiums.
A change related to the ACA is a trend away from fully insured service and toward Administrative Services Only (ASO) coverage. Rather than providing a set of benefits for the premium, companies purchase backroom administration—enrollment of their people in the claims process and payment of checks. The cost of the care is paid for by the company that buys the administrative services, making them self-insured. Previously only large companies would consider self-insuring, but the rising popularity of ASOs offers additional possibilities and arrangements that are now available to smaller employers.
Clinical Significance.—Third-party payer systems are complicated and becoming more so. The best course appears to be developing a highly efficient dental office that can handle a large volume of patients and provide excellent care for minimal cost. Maybe this needs to be added to the dental curriculum for future dentists.
DeWyze J: Dental reimbursement: The complicated reality of the third-party payer system. Inside Dentistry 12:92-94, 2016 Reprints not available
Leadership Learning leadership skills Background.—Every dentist must be a leader, but this is not something that comes naturally to everyone. However, leadership is a skill that can be learned and practiced effectively in a dental office. Six skills that are essential in developing leadership were explored. Essential Skills.—The dentist must create momentum whenever the dental team is working to achieve a goal or implement a new process. This will keep the team moving forward. An important part of momentum development is the inclusion of the team at all aspects of the process so that the team will pull together. In addition, the leader must make it clear for each individual involved how he or she will play a role in making the new initiative a success. This helps all team members commit to progressing together. The dentist must also be the example. If he or she doesn’t lead by example, the team sees this as a lack of commitment and can fail to engage in the process. This
234
Dental Abstracts
doesn’t mean that the dentist must get everything perfect the first time or that he or she must be the best at something. Instead, the focus is on being willing to take the first step and model the proper behavior for the team. The dentist should also be willing to celebrate wins. Everyone enjoys being recognized for doing a good job. Feedback is appreciated. Dentists must recognize, however, that constructive criticism also plays a role and not shrink from correction when needed. It is best to give the positive reinforcement publicly and save the correction for private moments. Investing in the team shows them that the dentist is committed not just to the endeavor but to the individuals involved. Often this is expressed as the provision of training to meet a goal. Training can be clinical, but also may involve customer service aspects of care. For example, improvements in communication skills with patients or others are fostered by modeling the behavior and then
Relevant Factors.—Factors that contribute to the problem of reimbursement include those related to the insurance industry and those involving Medicaid expansion. With respect to the insurance factors, a few PPOs have schedules of changes that reimburse a set amount per procedure. Most, however, establish a level of reimbursement that does not change from year to year. What changes constantly, however, are the data about the usual charges that form the basis for reimbursement. The data are collected by FAIR Health, an independent not-for-profit corporation designed to bring transparency to the costs of health and the health insurance industry. It maintains databases about dental charges across the country. Dentists submit information about what they charge (not what they are being reimbursed) on claims, and the information is passed along to FAIR Health. Carriers get aggregated FAIR Health data several times a year and insurers adjust the underlying rate for procedures based on the data. Generally the result is a slight change in rate. An analysis of the charges for pediatric dental services in all 50 states indicated that, after adjustment for inflation, the average charges in 31 states increased more than the inflation rate, but those in 19 states did not. In most cases, private dental insurance reimbursement has been keeping pace with inflation. However, the fees paid to dentists have not increased much and are often remaining stagnant at earlier levels. Insurance companies previously did not cover some procedures, such as implants and tooth whitening, but currently companies are saying that everything is covered but some of the coverage is zero. When this is translated into practice, insurers essentially set what dentists can charge patients for non-covered services. Dental associations are working to persuade legislatures to pass laws prohibiting this behavior, but the problem is being fought one state at a time. Assignment of insurance benefits is also a battleground for problems. Traditionally, if a practice does not participate in the plan, the benefit check is sent to the patient and the dentist is responsible for getting the money from him or her. Recently laws in a few states have allowed patients to assign their insurance benefits to dentists who aren’t in their dental plans. This approach makes patients happier, but often state dental associations don’t understand that they must pass such legislation before this can be done.
Volume 61
Issue 5
2016
233
The Affordable Care Act (ACA) has changed dental benefits by encouraging the expansion of Medicaid eligibility and increasing enrollment. The growth in the Medicaid market is like a tsunami. Medicaid reimbursement is historically low, but an increase in volume should be an excellent way to increase the total dollars a practice brings in. Some insurance companies have proposed that Medicaid reimbursements should be outcome-based rather than disease-oriented. In this way, dentists who perform better would be rewarded with higher reimbursement fees and direct referrals from call centers. Other rewards for performance include waiving prior authorizations based on the quality of the dentistry delivered. The quality of dentistry can also include having evening, weekend, or emergency hours available, which is a good thing for patients. Proposed Changes.—Plans are being proposed to help control costs, which would minimize the effect of low reimbursement rates. One trend is to create ‘‘narrow networks’’ of dental care providers, hospitals, and physicians who have demonstrated that they can provide care in a cost-effective manner with outcomes similar to those who charge more. Having a ‘‘narrow network’’ choice to offer clients may actually increase the level of benefits available to members while lowering employers’ premiums.
A change related to the ACA is a trend away from fully insured service and toward Administrative Services Only (ASO) coverage. Rather than providing a set of benefits for the premium, companies purchase backroom administration—enrollment of their people in the claims process and payment of checks. The cost of the care is paid for by the company that buys the administrative services, making them self-insured. Previously only large companies would consider self-insuring, but the rising popularity of ASOs offers additional possibilities and arrangements that are now available to smaller employers.
Clinical Significance.—Third-party payer systems are complicated and becoming more so. The best course appears to be developing a highly efficient dental office that can handle a large volume of patients and provide excellent care for minimal cost. Maybe this needs to be added to the dental curriculum for future dentists.
DeWyze J: Dental reimbursement: The complicated reality of the third-party payer system. Inside Dentistry 12:92-94, 2016 Reprints not available
Leadership Learning leadership skills Background.—Every dentist must be a leader, but this is not something that comes naturally to everyone. However, leadership is a skill that can be learned and practiced effectively in a dental office. Six skills that are essential in developing leadership were explored. Essential Skills.—The dentist must create momentum whenever the dental team is working to achieve a goal or implement a new process. This will keep the team moving forward. An important part of momentum development is the inclusion of the team at all aspects of the process so that the team will pull together. In addition, the leader must make it clear for each individual involved how he or she will play a role in making the new initiative a success. This helps all team members commit to progressing together. The dentist must also be the example. If he or she doesn’t lead by example, the team sees this as a lack of commitment and can fail to engage in the process. This
234
Dental Abstracts
doesn’t mean that the dentist must get everything perfect the first time or that he or she must be the best at something. Instead, the focus is on being willing to take the first step and model the proper behavior for the team. The dentist should also be willing to celebrate wins. Everyone enjoys being recognized for doing a good job. Feedback is appreciated. Dentists must recognize, however, that constructive criticism also plays a role and not shrink from correction when needed. It is best to give the positive reinforcement publicly and save the correction for private moments. Investing in the team shows them that the dentist is committed not just to the endeavor but to the individuals involved. Often this is expressed as the provision of training to meet a goal. Training can be clinical, but also may involve customer service aspects of care. For example, improvements in communication skills with patients or others are fostered by modeling the behavior and then