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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