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CDBP voices concern to United Concordia Companies on radiograph policy change

December 10, 2012

By Kelly Soderlund

When it comes to advocating for members, the Council on Dental Benefit Programs may not win every time but it does try its hardest to achieve a positive result.

CDBP staff and council members became aware in November that United Concordia Companies Inc. is changing its periapical radiograph policy in Washington, Oregon, Idaho and Montana on Jan. 1, 2013. Originally, the carrier planned to deny all periapical radiographs taken concurrently with a periodic evaluation.

The previous communication from UCCI stated that periapicals taken in conjunction with a periodic exam will be denied. Dentists would have to file an appeal after receiving a denial from UCCI.

“The FDA guidelines accepted by the ADA and American Academy of Pediatric Dentistry do not include routine periapicals with a periodic evaluation, but there can be legitimate reasons for taking them as described in the new communication,” said Dr. David May, CDBP chair.

“Whether a patient has a specific complaint that must be investigated, the dentist notices something abnormal that requires a radiograph to complete the diagnosis or there is a need to monitor growth and development, there are legitimate reasons to take periapical radiographs. The point of agreement between UCCI and the ADA is that periapical radiographs should not be taken routinely during a periodic evaluation.”

CDBP staff began a dialogue with UCCI executives, voicing concern that dentists would be required to file an appeal to be paid, even when proper justification was submitted.

There was an agreement that justification was in order to provide treatment outside the guidelines but that the justification submitted with the initial claim should be sufficient for payment. UCCI agreed to this, but it didn't end there.

Beginning Jan. 1, for periapical radiographs taken with a periodic evaluation, UCCI will begin requiring dentists to submit both justification and a copy of the radiograph.

“CDBP sees the rationale for the justification, but not to submitting a copy of the radiograph,” Dr. May said.

“The issue is the reason for taking the radiograph, not what is subsequently seen on the radiograph. For this reason, CDBP is still unable to understand the rationale for requesting a copy of the radiographs. The procedure in question is the taking of the radiographs, not any subsequent procedure or diagnosis. This is the only issue when deviating from the guidelines. Review of the radiographs will not provide more information about the reason for taking the radiographs than will the written justification, and it's an unnecessary burden when the doctors are already being asked to do a completely new thing. What if there is an absolutely legitimate reason for taking the radiographs, but they serve to rule out a problem? There will be nothing to note on the radiograph.”

CDBP members and staff believe the policy change presents an opportunity to explain the position on justification for treatment performed outside accepted guidelines.

“Dentistry has not had much experience with this because dentists do not submit a diagnosis with their claims. Health care providers will be accountable for the care they provide and there is no reason to disagree if the required justification is based on guidelines that the ADA accepts,” Dr. May said.

The ADA is actively involved in evidence-based dentistry and the Dental Quality Alliance to ensure that guidelines and quality measures are developed appropriately and that diagnosis is linked to treatment correctly. It is likely a diagnosis will eventually be required for all treatment, Dr. May said.

“The success we had with the UCCI payment policy is that the claim will be paid on initial submission if justification is submitted with the claim,” Dr. May said. “There is no disagreement that routine periapical radiographs with a periodic evaluation will be denied.”

At its meeting Nov. 16, CDBP discussed where dental financing is headed, what future preparations need to be made and what the ADA can do to proactively influence dental financing.

Guidelines, risk assessment and diagnosis were included in that discussion, and the ADA is at the table to see that these aspects of dental care are developed and used appropriately.

“Although the outcome is not entirely what we had hoped, this is a good example of CDBP going to bat for ADA members,” Dr. May said.

“Many times throughout the year, CDBP staff will contact dental benefit plan carriers to discuss issues that affect member dentists and/or the public. While contractual issues and plan design may limit the desired changes, most carriers are open to discussion.”