The Dentist’s Guide

1. DentalBenefit Plans NYSDA The Dentist’s Guide Understanding Your Patients’ Dental Benefits

2. Table of Contents • Dental Benefits • Benefit Plan Provisions • Types of Plans • Fraud and Abuse • Claim Submission • FAQ’s

3. Dental Benefits • What are dental benefits? • Why employers offer dental benefits? • Dental benefits and your practice

4. What are dental benefits? Provisions in the contract between an employer and employee that helps cover the cost for the employee to maintain or improve their oral health.

5. Why Employers Offer Dental Benefits? Companies give dental benefits to • Decrease employee absences • Prevent poor work performance • Maximize profit margin • Aid employee recruitment & retention

6. Dental benefits and your practice • Who has benefits? • What are “benefit plan provisions?” • How are “coordination of benefits” determined? • Is there an “assignment of benefits?” • Are “co-payments” due?

7. Who has benefits? • Patients must verify “eligibility” • Verifying a patient’s coverage is a courtesy • A patient may not be eligible for benefits • Unless dentist is a “participating provider,” eligibility cannot be guaranteed • Documentation of eligibility includes “effective date of coverage”

8. Who has benefits? • If applicable, the patient must know the “expiration date” • There may be a period of limited coverage after the expiration date called an “extension of benefits”

9. Benefit Plan Provisions • Parameters in the patient’s plan that affect their reimbursement* • These parameters will help in determining the coordination of benefits, the assignment of benefits, and the amount of co-payment. *These provisions should never influence the quality of care delivered to the patient.

10. Benefit Plan Provisions • Limitations of Coverage • LEAT or LEPAAT • Pre-Existing Conditions • Exclusionary Period • Proof of Loss • Coordination of Benefits • Non-duplication of Benefits • Maintenance of Benefits

11. Limitations of Coverage • Sometimes called “exceptions” or “exclusions” • Restrictive conditions in a dental benefits contract affecting how an individual or group is covered

12. Limitations of Coverage Examples: • age restrictions • (ex.: sealants covered to age 12) • time limitations • (ex.: children covered to age 21) • waiting periods • (ex.: 3 months before coverage starts) • benefit exclusions • (ex.: no orthodontics)

13. Least Expensive Alternate Treatment • LEAT, also called “the least expensive professionally acceptable treatment” (LEPAAT) • Restricts benefit allowance to coverage for the least expensive method of treatment* *Determination of benefits is independent of the final treatment decision made by the dentist and the patient.

14. Pre-existing Conditions • An oral health condition that existed before the patient was enrolled in the dental benefit program • Benefit plans will only cover a loss incurred while the patient is covered

15. Pre-existing ConditionsExample: A patient missing a 1st molar prior to coverage will not get a benefit for a fixed bridge or a removable partial denture

16. Exclusionary Period The period of time, defined by the dental benefits contract, in which a reimbursable restoration or procedure is functional (its life-span)

17. Exclusionary PeriodExample: If a replacement for a single crown will only be reimbursed if the original is greater than 5 years old then its exclusionary period is 5 years

18. Proof of Loss • Valid documentation of the covered patient’s treatment includes dates, costs, records, and approved codes and forms. • This information is needed to determine the financial liability of the company providing dental benefit plan

19. Coordination of Benefits • When a patient is covered by more than one dental benefits plan • The liability for each plan is determined by the contract

20. Coordination of Benefits Coverage will be designated as “primary” and “secondary” with assigned liabilities, benefits for specific procedures, and reimbursements by the plan administrators.

21. Non-duplication of Benefits By contract, many dental plans will not give a benefit if the plan is the patient’s “secondary” coverage.

22. Non-duplication of BenefitsExample: • Patient will not receive 100% reimbursement for procedure usually reimbursed by either plan at 50% • Patient will receive only the 50% from the “primary” coverage • “Secondary” plan will not pay benefit because of non-duplication clause in the contract.

23. Maintenance of Benefits • Assuming that the benefit of the secondary coverage is higher than the primary • The secondary coverage will reimburse the difference, if the allowable has already been met by the primary

24. Maintenance of Benefits • If the benefit of the primary coverage is equal or higher then the secondary coverage pays nothing. • This preserves or maintains the benefit, at least to the level of the secondary coverage.

25. Types of Dental Benefit Plans • Fee-for-Service • Managed Care • Discount / Referral

26. Dental Benefit Plans Dental benefit plans generally are divided into two categories: • Fully insured • Self-funded

27. Dental Benefit Plans Fully insured plans • The financial risk is transferred to the insurance company. • The plan and the insurance company are subject to state insurance laws and regulations.

28. Dental Benefit Plans Self-funded plans • The worker’s employer, union, or group assumes the financial risk. • Self-funded plans are regulated primarily by U.S. Labor Department under federal ERISA statutes (Employee Retirement Income Security Act).

29. Fee-for-Service Dental Plans • Traditional Fee-for-Service • Direct Reimbursement • Indemnity Plans

30. Traditional Fee-for-Service • Dentist provides service • Dentist determines fee • Patient pays for service • No coverage. No limitations • No exclusions. No third party Financial relationship Dentist Patient Medical-legal relationship Traditional fee-for-service is not a dental plan, but is included in this presentation to provide us with the base line or null plan

31. Direct Reimbursement • DR is a self-funded dental benefits plan • Employee pays for treatment from any dentist • Employee reimbursed for dollars spent on treatment

32. Direct Reimbursement • Reimbursement dictated by employer’s plan design • DR is ADA’s recommended form of 3rd party reimbursement • Coverage is limited to the money in the patient’s DR account maintained by the employer

33. Direct Reimbursement • Go to the ADA’s website for more info Employer Financial relationship Financial relationship Dentist Patient Medical-legal relationship

34. Indemnity Plans • Fully insured or self-insured plans • Patients receive benefits regardless of dentist they select • Predetermined reimbursement for specific services, regardless of dentist’s actual charges • Payments to enrollees or, with authorization, to dentist directly

35. Indemnity Plans • Fully insured indemnity plan relationships Contractual Insurance Co. Employer Financial (Reimbursement) Authorization Financial Patient Dentist Medical-legal

36. Indemnity Plans • Self-funded plan relationships Employer / Union / or Group Authorization Financial (reimbursement) Financial Patient Dentist Medical-legal

37. Indemnity Plans Limit coverage by . . . • Using a “deductible” • Use of a “UCR schedule” • Having a “schedule of allowance” • Establishing an “annual maximum” • Paying for the “least expensive alternative treatment” (LEAT)

38. Indemnity Plans Deductibles • A per patient or per family charge that is not reimbursed by the dental plan at the initial use of the plan for its calendar year • Requires patients out-of-pocket contribution to fee

39. Indemnity Plans The UCR Schedule • UCR = “usual, customary, and reasonable” • Actually benefit company’s proprietary basis for its reimbursement allowance • No defined relationship to any dentist’s actual fees

40. Indemnity Plans The UCR Schedule • Determined contractually between 3rd party and plan purchaser • Provides reimbursement based on percentile of UCR schedule • “Co-payment” equals difference between plan’s allowable benefit and dentist’s actual fee

41. Indemnity Plans Schedule of Allowance • Lists covered services and shows how much the plan will pay for each service. The patient is responsible for the difference, the “co-payment”

42. Indemnity Plans Annual Maximum • Maximum amount that insurance plan will pay during a calendar year, after the patient has met required deductible • Establishes a limit of liability, per individual or family

43. Indemnity Plans LEAT clause • Restricts benefit allowance to coverage for the least expensive method of treatment • Independent of the final treatment decision made by the dentist and the patient

44. Managed Care Plans • Preferred or Participating Provider Organizations (PPOs) • Closed Panel PPOs • Health Maintenance Organizations (HMO)

45. Managed Care Plans Changes reimbursement • Plan may reimburse dentist directly • Patient may receive different reimbursement for using “in-plan” or “out-of-network” dentist

46. Managed Care Plans • Designed to reduce health care costs • Presume over-utilization of treatment services • Transfer portion of financial liability from 3rd party and patient to doctor • Reduce alleged “over-treatment” through financial disincentives to treat

47. Managed Care Plans • Requires dentist to contract with managed care company or other 3rd party payer, directly or through subcontractor • Subcontracting groups include: • IPA (Independent Practice Association) • PPO (Participating Provider Panels) • LLC (Limited Liability Corporations)

48. Managed Care Plans • Dentist’s fees limited by contract • Services are either covered, or non-covered, or excluded from coverage • Co-payment for non-covered or excluded services may be determined by contract, otherwise it is traditional fee-for-service

49. Managed Care Plans • Fully insured managed care plan relationships Contractual Insurance Co. Employer Contractual Financial (assignment) Financial (non-covered) Patient Dentist Medical-legal

50. Managed Care Plans • Self-funded managed care relationships Employer / Union / or Group Contractual Financial (assignment) Financial Patient Dentist Medical-legal