Download Dental Benefit Plans:The Dentist`s Guide to Understanding Patients

NYSDA
The
Dentist’s Guide
Dental
Benefit Plans
Understanding
Your Patients’
Dental Benefits
NYSDA
Table of Contents
Table of Contents
Dental Benefits
Plan Provisions
Types of Plans
• Dental Benefits
• Benefit Plan Provisions
• Types of Plans
• Fraud and Abuse
Fraud and Abuse
• Claim Submission
Claim Submission
• FAQ’s
FAQ’s
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Dental Benefits
Table of Contents
Dental Benefits
• What are dental benefits?
Plan Provisions
Types of Plans
Fraud and Abuse
• Why employers offer dental benefits?
• Dental benefits and your practice
Claim Submission
FAQ’s
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Why Employers Offer Dental Benefits?
Companies give dental benefits to
• Decrease employee absences
• Prevent poor work performance
• Maximize profit margin
• Aid employee recruitment & retention
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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?
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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”
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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”
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Table of Contents
Dental Benefits
Plan Provisions
Types of Plans
Fraud and Abuse
Claim Submission
FAQ’s
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 copayment.
*These provisions should never influence
the quality of care delivered to the patient.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Limitations of Coverage
• Sometimes called “exceptions” or
“exclusions”
• Restrictive conditions in a dental
benefits contract affecting how an
individual or group is covered
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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)
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA 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.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Pre-existing Conditions
Example:
A patient missing a 1st molar
prior to coverage will not get
a benefit for a fixed bridge or
a removable partial denture
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Exclusionary Period
The period of time, defined by
the dental benefits contract, in
which a reimbursable
restoration or procedure is
functional (its life-span)
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Exclusionary Period
Example:
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Coordination of Benefits
Coverage will be designated as
“primary” and “secondary” with
assigned liabilities, benefits for
specific procedures, and
reimbursements by the plan
administrators.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Non-duplication of Benefits
By contract, many dental
plans will not give a benefit if
the plan is the patient’s
“secondary” coverage.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Non-duplication of Benefits
Example:
• 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.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Types of Dental Benefit Plans
Table of Contents
Dental Benefits
Plan Provisions
Types of Plans
•
Fee-for-Service
•
Managed Care
•
Discount / Referral
Fraud and Abuse
Claim Submission
FAQ’s
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Dental Benefit Plans
Dental benefit plans generally
are divided into two categories:
– Fully insured
– Self-funded
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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).
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Fee-for-Service Dental Plans
• Traditional Fee-for-Service
• Direct Reimbursement
• Indemnity Plans
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Medical-legal relationship
Patient
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Direct Reimbursement
• DR is a self-funded dental benefits plan
• Employee pays for treatment from any
dentist
• Employee reimbursed for dollars spent
on treatment
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Direct Reimbursement
• Go to the ADA’s website for more info
Employer
Financial relationship
Dentist
Medical-legal relationship
Patient
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Indemnity Plans
• Fully insured indemnity plan relationships
Insurance Co.
Contractual
Employer
Authorization
Dentist
Financial
Medical-legal
Patient
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Indemnity Plans
• Self-funded plan relationships
Employer / Union / or Group
Dentist
Financial
Medical-legal
Patient
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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)
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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”
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Managed Care Plans
• Preferred or Participating Provider
Organizations (PPOs)
• Closed Panel PPOs
• Health Maintenance Organizations (HMO)
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Managed Care Plans
Changes reimbursement
– Plan may reimburse dentist directly
– Patient may receive different reimbursement for
using “in-plan” or “out-of-network” dentist
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
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)
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Managed Care Plans
• Dentist’s fees limited by contract
• Services are either covered, or noncovered, or excluded from coverage
• Co-payment for non-covered or
excluded services may be
determined by contract, otherwise it
is traditional fee-for-service
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Managed Care Plans
• Fully insured managed care plan relationships
Insurance Co.
Contractual
Employer
Financial
(non-covered)
Dentist
Medical-legal
Patient
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Managed Care Plans
• Self-funded managed care relationships
Employer / Union / or Group
Dentist
Financial
Medical-legal
Patient
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Dentist Contracts - PPO
• Participating Provider
Organizations [PPOs]
• Contract with dentists for fee
discounts and other concessions
• Contract with insurance companies
or benefit plans to offer discounted
benefits through panel dentists
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Dentist Contracts - PPO
• Most common form of managed
care in dentistry.
• Dentists negotiate individually
with PPO.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Dentist Contracts - IPA
• Independent Practice Associations [IPA]
are a type of integrated group practice:
i.e., P.C., LLC
• Therefore IPA can enter into contracts
and negotiate fees on behalf of member
doctors
• Contracts with doctor-members
• Contracts only with HMOs to provide
dentists to treat HMO member-patients
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Dentist Contracts - LLC
• Limited Liability Corporations [LLC] are
a type of integrated group practice: i.e.,
P.C.
• Therefore LLC can enter into contracts
and negotiate fees on behalf of member
doctors
• Contracts with doctor-members
• Contracts with PPOs, HMOs, or benefit
companies directly to provide dentists
to treat patients enrolled in discount
dental plans
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Preferred Provider Organizations
• Contract with dentists for discounted
fees and other concessions
• May be fully insured (insurance
company’s risk) or self-insured
(employer’s risk)
• Cost employers less than similar
indemnity plan
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Preferred Provider Organizations
• Employees select a dentist from a
network.
• Employees may have to pay a copayment to the dentist, depending
on the service.
• Employees may have a point-ofservice option.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Point-of-Service Option
• Patients may receive some
benefit even when treated by an
“out-of-network” dentist.
• These patients get a significantly
reduced benefit.
• Patients pay the difference.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Closed Panel PPO
Plan makes no reimbursement
when care is provided by nonparticipating dentist
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA Health Maintenance Organizations
• Contracts with individual dentists
or groups (e.g. PPOs, IPAs, etc.)
• Benefit paid directly to providers,
not patients
• Patients restricted or encouraged
to see enrolled doctors to receive
benefits
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA Health Maintenance Organizations
• Transfers financial liability from
third-party and/or patient to
dentist
• Provides financial disincentives to
treatment
• Popular with employers to reduce
costs of health benefit package
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA Reimbursement in Managed Care
• Fee-for-service
• Capitation
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA Reimbursement in Managed Care
• Dentist contract with benefit plans or
group to accept specific fees from plan
• Fees may be discounted or eliminated
• Fees may be supplemented by fixed
patient co-payments
• Certain procedures may not be covered
• Dentist may forfeit ability to collect from
patients for certain treatment
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Reimbursement in Managed Care:
NYSDA
Capitation
• Fixed monthly payment, per
patient or family, regardless of
services rendered
• Does not alter dentist’s fiduciary
responsibility to deliver
appropriate care
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Reimbursement in Managed Care:
NYSDA
Capitation
Dentist’s income determined by:
– Negotiated capitation fees to dentist
– Size of enrolled panel assigned to
dentist
– Period of patient enrollment
– amount of treatment required by
patients in panel
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Discount / Referral Dental Plans
• Discount / Referral plan relationships
Third Party Marketers
Dentist
Financial
Medical-legal
Patient
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Discount / Referral Dental Plans
• Third party marketers establish
schedule of fees
• Dentists contract with third-party
marketer to charge enrolled patients
based on established fee schedule
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Discount / Referral Dental Plans
• Patients enroll for a monthly charge
• Patients given list of contracted dentists
• Dentists discount their normal fees in
exchange for prospective referrals
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Discount / Referral Dental Plans
• Plan pays no actual benefits
• Patients pay all dental fees directly to dentist
• “Coverage” limited to fee discount in dentist’s
contract with marketer
• Non-listed services may be discounted as per
the contract, otherwise traditional fee-forservice
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Table of Contents
Examples of Fraud and Abuse
• Fee Forgiveness
Dental Benefits
Plan Provisions
Types of Plans
Fraud and Abuse
• Coupons
• False Diagnosis
• Claims Padding
Claim Submission
FAQ’s
• Misrepresentation
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Examples of Fraud and Abuse
• Over-utilization
• Refund of fee to patient
• Upcoding
• Unbundling
• Billing for services not performed
• Other Fraudulent Schemes
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Actions Against Fraud and Abuse
• Restitution
• Civil litigation
• Criminal prosecution
• Professional Discipline
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Actions Against Fraud and Abuse
Professional Discipline:
– censure
– fines
– license probation
– license suspension
– license revocation
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Plan Regulation
• Plans are regulated by NYS
Insurance Laws
• Managed Care Plans (HMOs)
also regulated by NYS
Department of Health
• Self-funded plans are regulated
by US Department of Labor
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
How to Remediate Plan Violations
Violations of Managed Care Contracts
– Dentist may impose sanctions defined in
contract
– Dentist should consult with attorney
regarding contract violations
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
How to Remediate Plan Violations
Patient Contract Violations
– Utilize appeal procedures
– Complain to plan
– Complain to plan purchaser (i.e.
employer)
– Complain to NYS Insurance Dept.
– Complain to US Dept. of Labor (selffunded plans)
– Consult with attorney
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Claim Submission
Table of Contents
Dental Benefits
Plan Provisions
Types of Plans
• Patient claim must specify type of
treatment received
• Date of service
Fraud and Abuse
• Name of treating dentist
Claim Submission
• Dentist’s actual fee for patient’s treatment
FAQ’s
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Claim Submission
• Dentists are not required to submit
patient claims
• Dentists under contract to a managed
care company may be contractually
obligated to submit claims for enrolled
patients
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Claim Submission
• Claim forms may allow patient to authorize
payer to send insured’s benefit directly to
the treating dentist
• This is purely a courtesy
• Authorization is NOT binding on the payer
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
When Submitting Claims . . .
Dentist must provide
– Accurate patient & provider information
– Accurate treatment information
• Date of treatment
• Types of treatment (CDT codes)
– Accurate fee information
– Timely claim submission
– Copies of records, when requested
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Substitute Benefits –
CDT Code Changes
• Carrier extends alternate benefit
when treatment service is not
covered
• Payment made for less expensive
alternative when service is not
covered
• If service is covered, alternate
treatment must be clinically
appropriate for patient
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
3rd Party Dental Consultants
• Anyone may determine whether the
policy covers services and patient is
eligible for benefits
• When rendering decisions about quality
or appropriateness of patient care
– Must be licensed dentist in state where
patient is treated
– Evaluating patient care and treatment
planning are facets of the practice of
dentistry
– All state regulatory statutes and guidelines
apply
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
When may 3rd party deny a claim?
(Indemnity)
•
•
•
•
•
•
•
•
•
Patient not covered by policy
Services not performed
Dentist did not charge patient for treatment
Services not covered
Services exceed policy limitations
Deductible not met
Patient benefits expended
Benefits received exceed plan allowable
Claim submitted beyond allowable time
limit
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
When will 3rd party payer deny a
claim? (Managed Care)
• Dentist not under contract in “closed
panel” plan
• Services excluded from coverage
• Services do not conform with plan
definitions for “medical necessity” or
“standard of care”
• Dentist’s maximum reimbursement
exceeded
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
When must a 3rd party payer pay
a claim?
• Patient enrolled in plan
• Treatment services covered
• Treatment within policy guidelines
• Patient eligible for benefits
• Deductible has not been met
• Annual maximum not reached
• Allowable reimbursement not met
by second carrier
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
When can claim denials be
appealed?
NYSDA
•
•
•
•
Treatment is covered by policy
Patient eligible for benefits
Denial based on “standard of care”
Denial based on “least expensive
alternative treatment” clause – and
alternative is not clinically
appropriate for patient
• Denial based on “medical necessity”
• Question about qualifications of
consultant
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
How can denials be appealed?
• 3rd party payer must provide internal
review of disputed claim
• 3rd party payer must then provide
objective external review
• Peer Review – under certain conditions
• Patient may sue for contractual
violations
• Possible 3rd party legal violations
– Complain to NYS Insurance Department
– Complain to self-funded plan under ERISA
to US Labor Department
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Assignment of Benefits
• In true “assignment,” the doctor
becomes the benefit recipient;
e.g., No-Fault, Medicaid, some
managed care
• If payment is disputed, the doctor
engages in the dispute
• If no benefit is available, the doctor
loses recourse to seek payment from
the patient
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
NYSDA
Frequently Asked Questions
• E-mail questions to NYSDental.org
• Responses will be e-mailed back
• New dental benefit info will be posted
on this site.
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s