ADA and payers convey concerns, ideas
New series examines dental benefit trends and issues
|
Posted March 8, 2006 |
By Arlene Furlong This article is the first of an ADA News series on dental benefit trends and issues that will seek to explain changes in the industry, common problems faced by dentists and what’s being done to eliminate those problems, wherever possible.
This first article looks at new marketplace developments, factors influencing those changes and efforts by the ADA and payers to forge mutually productive relationships.
Gaps of understanding between the dental profession and the payer industry are nothing new. But Association efforts to bridge those gaps are intensifying.
Last month, Dr. James Mercer, chair, Council on Dental Benefit Programs and Dr. James Bramson, ADA executive director, hosted a meeting with leaders of Delta Dental Plans Association at ADA Headquarters in Chicago.
|
Dental benefit plan types
• An indemnity plan is a fully insured or self-insured plan where an assigned payment is provided for specific services, regardless of the actual charges made by the provider. Payment may be made to enrollees or, by assignment, directly to dentists.
• Preferred provider organization programs are managed care plans under which patients select a dentist from a network or list of providers who have agreed, by contract, to discount their fees.
• Dental health maintenance organization 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.
• 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. There is no reimbursement to the patient or to the provider.
• Direct reimbursement is a self-funded program in which the individual is reimbursed based on a percentage of dollars spent for dental care provided, and which allows beneficiaries to seek treatment from the dentist of their choice.
|
|
In January, the ADA met with leaders of the National Association of Dental Plans. NADP member companies represent some 67 percent of the estimated 159 million Americans covered by dental insurance plans. DDPA is the coordinating organization for Delta Dental Plans throughout the country.
"As the voice of the dental profession, the ADA is making positive strides in the relationship between dentistry and the dental benefits industry," Dr. Bramson said after the meetings. "Improved communications will lead us to a better understanding of the issues we share in common."
Evidence of relationship building in 2005 included cooperative efforts between the Association and the payer community on Hurricane Katrina relief efforts, industry support for the National Fluoridation Symposium 2005 and participation in the Give Kids A Smile initiative. Additionally, in 2004, the ADA negotiated a unique licensing program with NADP for the use of the Code on Dental Procedures and Nomenclature, assuring that third-party carriers are using the most current and correct version of the code.
Opportunities for two-way communications have resulted in third-party carriers being more receptive to the ADA in areas that concern grassroots members. Helping the industry gain a keener understanding of issues from the perspective of the ADA member is a major focus of the meetings, according to Dr. Mercer.
"It makes sense if we can reach mutually satisfactory resolutions to our problems by working directly with national carrier organizations," Dr. Mercer explained at the meeting. "There's a lot to be gained by working together."
The ADA Council on Dental Benefit Programs maintains a close watch on industry trends, tracks complaints from members and, when appropriate, works with individual companies to seek solutions.
After the February meeting, Dr. George Levicki, DDPA board chair, said, "In-person meetings are always valuable because they allow people sitting on different sides of the table to express their concerns and consider areas of interest for potential collaboration."
The Association discussed with both NADP and DDPA some of the problems and market trends associated with administration of dental benefit claims. Problems encountered by members who report them to the ADA include improper bundling and downcoding, claims delays and denials, X-ray return policies and payment explanations given to patients (explanation of benefit language).
Eradication of problematic EOB language that can be confusing to patients by not indicating that benefit limitations are based on patients' dental plan contracts, rather than dental treatment or fees, is moving forward, DDPA's Dr. Max Anderson, dental affairs advisor, said after last month's meeting with ADA leadership.
"We're changing a lot of the language so it does not inadvertently impugn the dentist," Dr. Anderson said. "The language will show benefits are contractual and the dentist is treating under a contract, not doing something wrong if benefits are denied."
The council and NADP are currently working together on a project toward a more standardized process to determine which claims require radiographs—and which ones do not—that the entire industry could agree on.
"This project, if successful, would be a win-win for industry and for every dentist in the United States," said Dr. Mercer. "Right now, because radiograph policies vary so much across the third party industry, radiographs are typically submitted with more frequency than necessary, simply because it is so difficult for dentists to determine which claims for which carriers require them. The ADA applauds NADP for its willingness to work on this project with the ADA."
Another area under discussion at the meetings is the definition and use of evidence based dentistry in plan design and claims payment. According to Dr. Daniel M. Meyer, associate executive director, ADA Division of Science, the ADA definition is that EBD is designed to be an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's needs and preferences.
Dr. Anderson said DDPA interests are to formulate policies and practices based on entire populations.
On another front, Jon Seltenheim, chair, NADP board of directors, reported to ADA representatives in January that actual growth in the number of new dental plans being sold has flattened in recent years due to the pressure on employers to deal with the escalating costs of their medical plans.
"Most employers are looking for ways to shift premium costs to employees in order to avoid reducing dental benefits," Mr. Seltenheim told ADA leaders. "They are also seeking managed care plan designs that offer a discount based on a PPO or HMO design."
Dental preferred provider organizations now dominate the market with an estimated 50 percent market share in 2004, up from 42 percent in 2002, according to a 2005 NADP/DDPA joint dental benefits report on enrollment.
The survey reveals a continuing trend toward dental PPO plans at the expense of dental health maintenance organizations and dental indemnity plans. Traditional fee-for-service indemnity plans now represent an estimated 27 percent of the market, down from an estimated 35 percent in 2002.
Dental HMOs have 14 percent of the market compared to 15 percent in 2002. Straight discount dental plans, similar to buyers' clubs, are growing and now claim 9 percent of the market. Direct reimbursement has an estimated 1 percent of the market. DR will be among plan types surveyed for the 2006 NADP/DDPA Joint Dental Benefits Report. (See chart, this page.)
Rising medical premiums are also responsible for more consumer-driven health plans, as employers look for ways to curb their medical costs. Higher deductibles are a common characteristic of consumer health plans.
"Consumers will have to make harder choices about where their out-of-pocket dollars go," explained Mr. Seltenheim. "If they have a $1,000 deductible, those dollars could be competing with medical expenditures. They'll be looking at dental as part of their overall out-of-pocket dollars, rather than separate from their medical expenses, and employers' support will go toward benefit choices overall, with dental being just one of them."
He said that what this means in terms of business realities for the dental benefits market are changes in plan design more than changes in the claims adjudication process. And while high deductible plans might discourage consumers from procuring preventive services, newer plan designs won't.
"Patients are going to have to understand the value of regular exams and prevention vs. the possibility of higher expenditures down the road," said Mr. Seltenheim.
|
