Committee on Dental Benefits



Committee on Dental Benefits

Meeting

June 25, 2010

Minutes

Present Absent

Dr. David Fox (2) Dr. Thomas Donahue (3)

Dr. Tad Glossner (5) Dr. Joseph Yatko (6)

Dr. Robert Callahan (7) Dr. Jon Johnston (8), ADA Consultant

Dr. Naila Naseem-Elkassas (8)

Dr. Ronald Helminski (9) Consultants/ Staff/Guests

Dr. Gino Pagano (10) Dr. Clayton Pesillo, UCCI

Dr. Donald Stoner (10), T/L Mr. James Shade, UCCI

Dr. Lauri Passeri (2), ADA Consultant Ms. Karen Witelsal, UCCI

Dr. Jerome Blum, UCCI

Dr. William Spruill (5), President

Ms. Marisa Swarney, director, government

Relations

Welcome/Chair’s Remarks

Dr. Glossner welcomed new members to the committee.

Approval of Minutes

The committee unanimously approved the minutes from the December 4, 2009, conference call.

Meeting with United Concordia (UCCI) Representatives

The committee asked and received answers to the following questions:

• Question: What is the clinical rationale to justify UCCI’s policy that a dentist cannot perform scaling and root planing 45 days before or after (or the same day) the dentist performs a prophy?

Answer: Due to misreporting by participating providers, UCCI had to establish a length of time. Its system can only account for a 45-day period, but it is reviewing whether the system can be changed. However, UCCI believes it is inappropriate for dentists to perform scaling and root planing, then perform a prophy, when periodontal disease had been identified. Dentists should perform periodontal maintenance instead of prophys. UCCI’s policy is to question a claim if a prophy falls within 45 days of scaling and root planing. UCCI believes that dentists are performing a palliative treatment and can be coded as such. UCCI believes that dentists who see patients for gingival abscesses should treat those abscesses and submit it as a palliative treatment or an I and D. Either of those codes may be used for this entity, but S/RP 1-3 teeth per quad will not be approved for treatment of a gingival abscess if there is no radiographic evidence of bone loss. Dr. Blum suggested that PDA consult the ADA for a different code for scaling of a gingival abscess if the current codes were not inclusive enough.

The committee requested that UCCI consider shortening the 45-day timeframe to 14 days, based on studies indicating that most patients recuperate within a two-week period and their gingiva is sufficiently healed.

• Question: What is the clinical rationale for UCCI’s policy relating to Code 0140 that suggests dentists should render treatment without first performing an examination and diagnosis? This insurance policy is counter to the State Board of Dentistry requirements found under the definitions of direct and general supervision.

Answer: UCCI believes the committee’s question is incorrect. This used to be UCCI’s policy but it changed three years ago. UCCI will now pay dentists for submitting claims for an examination, diagnosis and treatment given on the same day to patients who come in unexpectedly. If this happens twice in one year, UCCI will consider this an “uncovered billable” procedure and patients may be charged for the second visit.

• Question: What is the clinical rationale behind making 0460 a non-integral procedure if performed on a day different than the day that the root canal procedure is performed? How does UCCI determine what is integral to a procedure when there are separate ADA Codes?

Answer: UCCI considers pulp testing integral to all procedures and is rarely considered a separate procedure payable. If pulp testing is performed on a different day as other procedures, UCCI may consider it an “uncovered billable” procedure and patients may be charged, in the rare instances that a group requests that this be a covered procedure. This is the exception rather than the rule.

• Question: What is UCCI’s policy for assigning benefits when policyholders choose a dental provider outside of the network?

Answer: UCCI considers it a benefit for providers who participate in its plans. Pennsylvania is the only state as a whole that does not allow for assignment of benefits. However, there are limited cases where they will assign benefits if the employers’ group requests it. UCCI is considering removing this restriction overall. When dealing with divorced parents, arrangements for insurance payments must be made through a legal settlement or court order. Dentists should consider collecting the payment up front and letting the parents settle the issue themselves.

The committee noted that patients have the ability to talk to their employers about requesting an assignment of benefit from UCCI.

• Question: Please explain the new policy that requires general dentists to have to supply more documentation than periodontists in order to have scaling and root planing preauthorized. Does this apply to participating general dentists only?

Answer: The policy applies to all general dentists, not just participating providers. The letter sent to providers included the misprint that the policy would only apply to participating providers. In a pilot program in California, UCCI found that more 50 percent of general dentists are misreporting the presence of periodontal disease before performing scaling and root planing. According to UCCI, it is their impression that many general dentists believe that the mere presence of subgingival calculus indicates a need for scaling and root planing.

The committee agreed to research whether dental school periodontal programs’ classification of periodontal disease coincides with the American Academy of Periodontists’ definitions of periodontal disease, and whether either of these coincides appropriately with UCCI’s definition and treatment authorizations. The committee will publish information for members to suggest an appropriate way to file claims to UCCI using the correct definitions regarding periodontal disease. (06/10CDBDA1)

• Question: Does UCCI adjudicate claims in the United States?

Answer: Yes, and there are no plans to move claims processing outside of the United States.

• Question: Is there any advantage to sending pans and photographs with claims submission?

Answer: Yes, though radiographs and charts are paramount to approving claims.

• Question: If preauthorization is needed for scaling and root planing, is it appropriate to perform a debridement, then chart on the same day or subsequent to the visit? Will the debridement, scaling and root planing all be paid for?

Answer: That is appropriate and UCCI will pay for debridement (D4355) and scaling and root planing or a prophy, as long as they are not done on the same day. (It is not appropriate to do a comprehensive exam on the same day as performing code D4355). There does not need be 45 days between the debridement and scaling and root planing.

• Question: Does UCCI lease its network?

Answer: UCCI does lease its network outside of Pennsylvania. In Pennsylvania, all business is under UCCI with one exception of having business with Mutual Omaha.

• Question: Will UCCI withhold claims if requesting reimbursement for a previous claim?

Answer: UCCI may withhold claims, but only under extreme circumstances because this practice can be challenged in court. UCCI’s policy is to first request the money back and work with the provider to settle the issue.

• Question: Can dentists participate in UCCI’s Children Health Insurance Program (CHIP) without participating in all UCCI ‘s plans?

Answer: Yes, dentists may now participate in CHIP without participating in UCCI’s commercial plans. UCCI is contracted with Highmark to administer CHIP.

Insurance Liaison Program

The following members of the committee agreed to serve as liaison to dental insurance companies:

MetLife: Dr. Joseph Yatko

UCCI: Dr. Tad Glossner and Dr. Gino Pagano

Delta: Dr. Robert Callahan

Aetna: Dr. Ronald Helminski

Cigna: Dr. Naila Naseem-Elkassas

Guardian: Dr. Lauri Passeri

Miscellaneous: Dr. Gino Pagano

Review of Boilerplate Letter to Members

The committee reviewed the draft letter PDA will send to any member who calls with an insurance complaint. It was agreed that the letter should include language encouraging members to read insurance contracts carefully and use the American Dental Association’s (ADA) Contract Analysis Service before signing contracts.

Staff will revise the draft letter to members who contact PDA with insurance complaints, advising them to read insurance contracts carefully and use the ADA’s Contract Analysis Service. Staff will post the revised letter on the committee’s social networking page for final review (06/10CDBDA2)

Legislative Update

The committee reviewed SB 1222, legislation prohibiting insurers from capping non-covered services. Dr. William Spruill explained that legislators are debating whether to add language to SB 1222 that would prohibit dentists from charging their usual fees for covered procedures in situations where patients exhaust their maximum allowance in a given year.

A majority of the committee agreed that PDA should continue lobbying for the passage of SB 1222 without amendments. However, if it becomes clear that SB 1222 will “die” without an amendment that prohibits dentists from charging their usual fees for covered services when a maximum yearly benefit is met, the committee recommends adding the amendment to ensure passage of SB 1222. Dr. Spruill will forward the committee’s recommendation to PDA’s Board of Trustees for consideration should it become necessary as SB 1222 moves through the legislative process. (06/10CDBDA3)

Staff will post on the committee’s social networking page for review the National Conference of Insurance Legislators’ model legislation prohibiting insurers from capping non-covered services. (06/10CBDDA4)

HB 2509, legislation requiring insurers to assign benefits to non-participating providers directly after treatment is rendered to a subscriber, was assigned to the House Insurance Committee in May. It will most likely “die” at the end of the legislative session in November and will need to be reintroduced next session.

Member Resources

The committee agreed to the following:

• Dr. Lauri Passeri will research whether it would be beneficial for PDA to contract with Trojan Software, which provides important insurance coding and billing information, in order to offer its services to members for a discounted fee. Dr. Passeri will report her findings to the committee during its October 27 conference call. (06/10CDBDA5)

• Staff will research whether it would be beneficial for PDA to contract with Insurance Solutions in order to offer its services to members for a discounted fee. The Insurance Solutions newsletter answers questions for members who have problems with insurance companies. Staff will reports their findings to the committee during its October 27 conference call. (06/10CBDDA6)

• The committee will develop a schedule for sending insurance-related information to members via email on a monthly basis. Staff will work with Dr. Glossner to develop a list of topics and a schedule for when articles are due. Each committee member is responsible for writing at least one article by the established deadline. (6/10CBDDA7)

• Dr. Tad Glossner will research whether PDA can offer continuing education (CE) courses on proper coding and claims submission. The ADA may have speakers available for CE courses. (06/10CBDDA8)

New Business

Dr. Passeri recommended that PDA send a representative to attend the ADA’s National Benefits Conference on August 20, 2010, in Chicago. Staff will forward a request to PDA’s Budget, Finance and Property Committee to fund one representative’s attendance at the conference. (06/10CBDDA9)

The committee scheduled a conference call for Wednesday, October 27, 2010, at 7:00 p.m.

The meeting adjourned at 2:03 p.m.

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