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Understanding pretreatment review
434
Reviews
and
Am. J. Orthod.
abstracts
April
19i3
of periosteoplasty to cleft closure in human beings particularI) since the positivcl findings relate primarily to the nasal bone (which would not bc illvol\-txtl in human patients) a,nd the negative findings relate to masillar) structures. Similar1.v designed studies involving lower primates should logically pr~etlc widesprcaad application of periostcoplasty to human beings. ilpJ)Jic4atioll
Understanding C. A. Bethea Tronsnctions of Americnn Dental
Pretreatment
Review
the .$‘Srd ~‘ntionnl Dent& Henltk Association, Chicnyo, Ill., April
Conference, 24-26, 197.2
Dr. Bethea, who represents the Health Insurance Council (an organization of private commercial health insurers), states : “There are at present over 50 companichs who provide dental insurance. Xost of these require pretreatment review. ” He then continues : “Pretreatment review, when all is said and done, is a cost control device from the carrier’s point of view. Claim costs are reduced by an early and thorough analysis of the treatment plan and contract provisions. ” The Health Insurance Council subscribes to the following: The dentist is furnished a diagnostic and treatment form to fill out and is usually asked to provide the insurance company with roentgenograms and/or study models when the company feels it is necessary. The carrier returns the treatment plan and accompanying materials to the dentist with an evaluation of the services covered and benefits available. The dentist and his patient are then informed by the insurance company what they will pay or if they will not pay for any part of the treatment. This has occurred, to our knowledge, when the company’s “dental consultant” thought the denture or bridge could be constructed in a different manner than outlined in the treatment plan submitted by the practicing dentist. If the difference between the fee charged by the dentist and the payment by the insurance company is too much for the financial ability of the patient to bear, t’hc patient has the choice of seeking cheaper dental care elsewhere or foregoing all or part of the needed treatment. Dr. Bethea asks: “Are we intruding?” He answers his question as follows: “Consciously or unconsciously, a carrier [insurer or payer], a dental service corporation, or a governmental agency begins to intrude as soon as an agreement has been made that a t,hird party will pay a portion of t,he bill.” l)r. Bethea states further: “I share your distaste with the prospects of this intrusion. I am personally convinced that a pretreatment program can be successfully engineered without significant interruption of the doctor-patient relationship. ‘! The problem now facing the dental profession and its specialties is to reach a symbiotic arrangement with the “carriers” that will delimit the mutually cx4usive fields of operation of the third party and the profession and point UP areas of mutual cooperation that would benefit the insured patient. One of the foremost problems to be solved is what is termed “pretreatment review.”
Reviews
and
Am. J. Orthod.
abstracts
April
19i3
of periosteoplasty to cleft closure in human beings particularI) since the positivcl findings relate primarily to the nasal bone (which would not bc illvol\-txtl in human patients) a,nd the negative findings relate to masillar) structures. Similar1.v designed studies involving lower primates should logically pr~etlc widesprcaad application of periostcoplasty to human beings. ilpJ)Jic4atioll
Understanding C. A. Bethea Tronsnctions of Americnn Dental
Pretreatment
Review
the .$‘Srd ~‘ntionnl Dent& Henltk Association, Chicnyo, Ill., April
Conference, 24-26, 197.2
Dr. Bethea, who represents the Health Insurance Council (an organization of private commercial health insurers), states : “There are at present over 50 companichs who provide dental insurance. Xost of these require pretreatment review. ” He then continues : “Pretreatment review, when all is said and done, is a cost control device from the carrier’s point of view. Claim costs are reduced by an early and thorough analysis of the treatment plan and contract provisions. ” The Health Insurance Council subscribes to the following: The dentist is furnished a diagnostic and treatment form to fill out and is usually asked to provide the insurance company with roentgenograms and/or study models when the company feels it is necessary. The carrier returns the treatment plan and accompanying materials to the dentist with an evaluation of the services covered and benefits available. The dentist and his patient are then informed by the insurance company what they will pay or if they will not pay for any part of the treatment. This has occurred, to our knowledge, when the company’s “dental consultant” thought the denture or bridge could be constructed in a different manner than outlined in the treatment plan submitted by the practicing dentist. If the difference between the fee charged by the dentist and the payment by the insurance company is too much for the financial ability of the patient to bear, t’hc patient has the choice of seeking cheaper dental care elsewhere or foregoing all or part of the needed treatment. Dr. Bethea asks: “Are we intruding?” He answers his question as follows: “Consciously or unconsciously, a carrier [insurer or payer], a dental service corporation, or a governmental agency begins to intrude as soon as an agreement has been made that a t,hird party will pay a portion of t,he bill.” l)r. Bethea states further: “I share your distaste with the prospects of this intrusion. I am personally convinced that a pretreatment program can be successfully engineered without significant interruption of the doctor-patient relationship. ‘! The problem now facing the dental profession and its specialties is to reach a symbiotic arrangement with the “carriers” that will delimit the mutually cx4usive fields of operation of the third party and the profession and point UP areas of mutual cooperation that would benefit the insured patient. One of the foremost problems to be solved is what is termed “pretreatment review.”