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Transcript
For AGD Constituent Use Only Constituent Dental Care/Practice Chairperson’s Resource Manual September 2010 Originally Published: August 1992 Revised: November 1994 Revised: February 1997 Revised: March 1998 Revised: March 2000 Revised: March 2002 Revised: February 2004 Revised: March 2006 Revised: January 2007 Revised: September 2010 For AGD Constituent Use Only Table of Contents I. INTRODUCTION ......................................................................................................................................................5 II. ALTERNATIVE DELIVERY/PAYMENT SYSTEMS ......................................................................................6 ANTITRUST REGULATIONS: .....................................................................................................................................6 SIGNING A CONTRACT: ............................................................................................................................................7 CAPITATION PROGRAMS: ........................................................................................................................................8 CAPITATION-SURCHARGE PROGRAMS: ..................................................................................................................9 DENTAL SERVICE CORPORATIONS: ........................................................................................................................9 DIRECT REIMBURSEMENT PROGRAMS: ................................................................................................................ 10 ELECTRONIC CLAIMS AND THE NPI REQUIREMENT: .......................................................................................... 10 FEE SCHEDULE PROGRAMS: .................................................................................................................................. 11 FLEXIBLE BENEFIT PROGRAMS AND CAFETERIA PROGRAMS: ............................................................................ 11 HEALTH MAINTENANCE ORGANIZATIONS (HMOS): ........................................................................................... 11 INDIVIDUAL PRACTICE ASSOCIATIONS (IPAS): .................................................................................................... 12 INSURANCE-FREE PRACTICES: .............................................................................................................................. 13 MANAGED CARE: ................................................................................................................................................... 13 MANAGEMENT SERVICE ORGANIZATIONS (MSOS): ............................................................................................ 13 PREFERRED PROVIDER ORGANIZATIONS (PPOS): ............................................................................................... 14 TABLE OF ALLOWANCES/FIXED BENEFIT PROGRAMS:........................................................................................ 14 USUAL, CUSTOMARY, AND REASONABLE (UCR) PROGRAMS:............................................................................. 15 III. HOW TO RESOLVE CONFLICTS................................................................................................................. 16 SELF-FUNDED PROGRAMS: .................................................................................................................................... 17 AGD CHECKLIST FOR RESOLVING PROBLEMS WITH CARRIERS: ....................................................................... 17 AGD CHECKLIST FOR ................................................................................................................................... 18 RESOLVING PROBLEMS WITH CARRIERS .............................................................................................. 18 COMPLAINT REPORTING FORM: ........................................................................................................................... 20 AGD COMPLAINT REPORTING FORM ...................................................................................................... 21 PRE-APPROACH: .................................................................................................................................................... 24 Draft of a Pre-Approach Letter......................................................................................................................... 24 BENEFIT EXCLUSION CLAUSES: ............................................................................................................................ 25 Draft Response to Benefit Exclusion Clauses .................................................................................................. 25 LIMITATION OF BENEFIT BASED ON UCR: ........................................................................................................... 26 Draft Response to Limitation of Benefit Based on UCR ................................................................................. 27 WHEN A CARRIER CHANGES THE ORIGINAL TREATMENT CODE: ...................................................................... 28 Draft Response to a Carrier Changing the Original Treatment Code ............................................................ 28 DENIAL OF BENEFITS WHEN TREATING FAMILY MEMBERS: .............................................................................. 29 DENIAL OF PAYMENT FOR COVERED PROCEDURES PER THE CONTRACT LANGUAGE:...................................... 29 PROFESSIONAL COURTESY:................................................................................................................................... 31 LOSS OF RADIOGRAPHS: ........................................................................................................................................ 31 MISDIRECTED PAYMENT OF BENEFITS: ................................................................................................................ 32 PERIODS OF PATIENT INELIGIBILITY: ................................................................................................................... 32 PRE-DETERMINATION: ........................................................................................................................................... 32 REDUCED BENEFITS FOR NON-CONTRACTING PROVIDERS: ................................................................................ 33 TWO-TIERED REIMBURSEMENT SYSTEMS: .......................................................................................................... 33 Draft Response to Two-Tiered Reimbursement Practices ............................................................................... 34 UNRETURNED REFERRALS: ................................................................................................................................... 35 UTILIZATION REVIEWS: ........................................................................................................................................ 35 Draft Response to Utilization Reviews .............................................................................................................. 36 DRAFT RESPONSE TO MISINTERPRETATION OF COORDINATION OF BENEFITS .................................................. 37 DRAFT RESPONSE TO DENIAL OF BENEFIT FOR SEALANTS.................................................................................. 38 2 For AGD Constituent Use Only DRAFT RESPONSE TO REJECTION OF CLAIM FOR OVERPAYMENT...................................................................... 39 DRAFT RESPONSE TO DENIAL OF BENEFIT FOR DENTIST WRITING A TOBACCO CESSATION PRESCRIPTION .. 40 AGD CHECKLIST FOR RESOLVING PROBLEMS WITH DENTAL PRODUCTS AND MATERIAL AND THE ............... 41 AGD CHECKLIST FOR RESOLVING PROBLEMS WITH DENTAL EQUIPMENT ............................................................ 41 AGD CHECKLIST FOR RESOLVING PROBLEMS WITH ......................................................................... 42 DENTAL PRODUCTS AND MATERIAL ....................................................................................................... 42 AGD CHECKLIST FOR RESOLVING PROBLEMS WITH ......................................................................... 44 DENTAL EQUIPMENT ................................................................................................................................... 44 IV. WORKING WITHIN ORGANIZED DENTISTRY .......................................................................................... 46 CDT ........................................................................................................................................................................ 46 SELECTING A DENTAL BENEFITS PLAN................................................................................................................. 46 YOUR STATE DENTAL ASSOCIATION OR LOCAL SOCIETY ................................................................................... 46 PEER REVIEW......................................................................................................................................................... 47 V. CURRENT AGD ADVOCACY POLICIES .................................................................................................... 48 Accreditation and Recognition of Non-Specialty Areas .................................................................................. 55 ADPAC .............................................................................................................................................................. 56 Advertising of Credentials ................................................................................................................................. 56 Advocacy Fund .................................................................................................................................................. 56 American Dental Association ........................................................................................................................... 56 Anesthesiology ................................................................................................................................................... 57 Annual Meeting ................................................................................................................................................. 57 Contracts............................................................................................................................................................ 57 Dental Anesthesiology ....................................................................................................................................... 58 Dental Auxiliaries ............................................................................................................................................. 58 Dental Practice .................................................................................................................................................. 60 Dental Consultant ............................................................................................................................................. 84 Dental Education .............................................................................................................................................. 84 Dental Laboratory Techniques ......................................................................................................................... 86 Dental Materials ................................................................................................................................................ 86 Dental Practices ................................................................................................................................................ 87 Dental Students ................................................................................................................................................. 88 Denturism .......................................................................................................................................................... 89 Direct Reimbursement....................................................................................................................................... 89 Dues ................................................................................................................................................................... 89 Enteral Conscious Sedation .............................................................................................................................. 90 Federal Services ................................................................................................................................................ 90 Fees .................................................................................................................................................................... 91 General Dentist.................................................................................................................................................. 91 General Practice Residency Program ............................................................................................................... 93 Geriatric Care .................................................................................................................................................... 94 Health Maintenance Organizations (HMO’s) ................................................................................................. 94 Health Planning ................................................................................................................................................ 94 HIV .................................................................................................................................................................... 94 Hospital Dentistry Privileges ............................................................................................................................ 95 Implants ............................................................................................................................................................. 95 Infection Control Measures Urged ................................................................................................................... 96 Infectious Waste ................................................................................................................................................ 96 Insurance, Malpractice ...................................................................................................................................... 97 Legislation ......................................................................................................................................................... 97 Licensing ......................................................................................................................................................... 107 Licensure ......................................................................................................................................................... 107 Limitation of Practice ..................................................................................................................................... 108 Malpractice Insurance and Litigation ............................................................................................................ 108 Mandated Health Benefits .............................................................................................................................. 108 3 For AGD Constituent Use Only National Health Program, Dentistry’s Position on ........................................................................................ 109 National Practitioner Data Bank .................................................................................................................... 109 OSHA ............................................................................................................................................................... 109 Patient Records................................................................................................................................................ 110 Pediatric Dentistry ........................................................................................................................................... 110 Peer Review Committees ................................................................................................................................. 110 Post Graduate Training .................................................................................................................................. 111 Public Information .......................................................................................................................................... 112 Radiographs .................................................................................................................................................... 112 Salaried Dentists.............................................................................................................................................. 112 Sedation ........................................................................................................................................................... 113 Smoking ........................................................................................................................................................... 113 Specialty License Laws.................................................................................................................................... 113 Specialty Listings ............................................................................................................................................. 114 State Board of Dentistry .................................................................................................................................. 114 Sterilization...................................................................................................................................................... 115 Surveys ............................................................................................................................................................. 115 Table of Allowances ........................................................................................................................................ 115 VI. ACCESS AND PREVENTION...................................................................................................................... 116 AGD ACCESS TO CARE WHITE PAPER................................................................................................................... 116 PREVENTION .......................................................................................................................................................... 117 VII. WORKFORCE / INDEPENDENT MIDLEVEL PROVIDERS ............................................................... 118 VIII. AVAILABLE RESOURCES .................................................................................................................... 118 RESOURCE STAFF................................................................................................................................................. 118 2010-2011 AGD DENTAL PRACTICE COUNCIL................................................................................................... 120 RESOURCE MATERIALS ....................................................................................................................................... 121 STATE DENTAL ASSOCIATION CONTACTS, TELEPHONE NUMBERS, AND ADDRESSES ...................................... 122 STATE DEPARTMENTS OF INSURANCE ................................................................................................................ 129 MEDWATCH:........................................................................................................................................................ 140 FEDERAL AGENCY CONTACT NAMES AND ADDRESSES: .................................................................................... 141 4 For AGD Constituent Use Only I. Introduction This manual is intended to assist you, the Constituent Dental Care/Practice Chairperson, in your role as ombudsman for your constituent’s general dentist members. Yours is a critical role—you are charged with collaborating with the Academy of General Dentistry’s (AGD) Dental Practice Council. You must therefore understand the impact of any issue that might affect the dental profession, the oral or related systemic health of the public, or the general practitioner’s right to practice. Today, more than ever before, the origins of issues affecting dentistry can have many sources: consumers and consumer action groups; third party payers; national and state legislation and regulation; and various health care organizations. As Constituent Dental Care/Practice Chairperson, you have demonstrated that you are truly interested in and concerned about dental benefit and dental practice issues that are facing the profession. Your responsibilities call for you to share information, initiate inquiries and work with AGD Headquarters staff and/or appropriate Dental Practice Council members relative to dental practice issues that are impacting (or may significantly impact) the practices of AGD members in your constituent. Specific responsibilities call for you to: 1. Be familiar with your state or provincial Dental Practice Act. 2. Keep your constituent informed about local dental practice and dental benefit issues, as well as national issues as summarized in the Dental Practice Council Action Summaries that will be forwarded to you within 30 days after each meeting. 3. Respond to constituent surveys and/or all other constituent outreach efforts by the Dental Practice Council. 4. Encourage your constituent editor to regularly publish appropriate articles and relevant dental practice information in your constituent newsletter. 5. Establish liaison with your state or provincial dental care and legislative committees. 6. Provide AGD Headquarters with appropriate documentation relative to the details of any dental practice issues occurring on a constituent level, which are impacting (or may significantly impact) the practices of the members of your constituent. You may also want to become involved in implementing an appropriate constituent dental care project. In many cases, this project should be accomplished in collaboration with your state or provincial dental care and/or legislative committees. 5 For AGD Constituent Use Only II. Alternative Delivery/Payment Systems General Virtually every allied health care field has had to defend itself against public media coverage of horror stories regarding the skyrocketing cost of care, provider abuse and the insurance industry’s application of various “fix-it” techniques. Dentistry has not been spared this type of negative coverage and, in fact, some would say that dentistry is a victim of this critical publicity because more and more frequently, the cost containment mechanisms used in medical plans are being applied to dental benefits programs with no regard for the most basic differences between the two fields. The big issue in insurance programs, particularly when it comes to dentistry, in which some procedures are perceived as being wholly elective, is cost containment. Yet insurance companies and insurance plan purchasers frequently fail to realize the most obvious difference between dentistry and medicine—dentistry does not require coverage for catastrophic care. While total medical/dental expenditures may account for an ever-increasing percentage of the Gross National Product, dentistry’s share of the total dollars spent on health care dollars is minuscule. Yet, as American businesses develop new programs to control health care costs, there is more interest in designing and implementing alternative and less costly systems to deliver health care to the public. AGD membership surveys have indicated that many AGD members have participated in one or more dental plans, including fee-for-service. This chapter includes the basic points of various health care delivery systems. The information presented here is intended to familiarize you with some of the plans currently available. It is strongly recommended that any dentist considering participation in any plan conduct a careful and thorough review of the program and its implications. Be aware that voluntary enrollment on the part of the patient can lead to adverse selection, which means that people who need the most care will enroll in greater numbers than those requiring a lower level of care. Definitions on the following pages that are marked by an asterisk (*) are based on the definitions contained in the Selecting a Dental Benefits Plan brochure published by the American Dental Association’s (ADA) Council on Dental Benefits. Antitrust Regulations: Like other health care professionals, dentists (and dental organizations) are bound by certain government regulations that can seriously restrict their activities or responses to situations perceived as threatening. As an illustration, dentists are frequently approached by third party carriers, which may appear to have great resources, to reduce or discount their fees, alter their reimbursement mechanisms, or change their practice profiles. However, the dental practitioner must be aware that certain reactions, such as price fixing, group boycotts, or even restraint of trade, may result in violation of antitrust regulations. 6 For AGD Constituent Use Only The penalties for these violations can be quite severe, including substantial fines, imprisonment, and losing one’s license to practice. Every practicing dentist should have at least a basic understanding of these terms and of the antitrust laws and their enforcement mechanisms. The ADA’s Division of Legal Affairs has issued a publication, The Antitrust Laws in Dentistry, which explains basic antitrust principles and serves as a guide to what actions may or may not be taken when dealing with fees, reimbursements, and third parties. The brochure is available free-of-charge to ADA members. Signing a Contract: When a dentist signs a contract to provide services, that contract is a legally enforceable document with responsibilities and obligations that could prove onerous, especially if they were not anticipated. To ensure that the dentist completely understands the terms and conditions of any agreement before entering into a contract, he or she should have the contract reviewed by legal counsel who is qualified to provide advice in this area. It is not within the scope of this manual to detail every caution to be aware of when signing a contract, but there are many questions that should be answered by the contract. The following questions are for illustrative purposes only and should not be considered to be a complete list. Is there a hold harmless clause? Do you incur liabilities if you sign it? If you are not comfortable performing certain procedures, will specialty referral be allowed? If so, under what conditions? Will you or the company choose the specialist? Will you be financially responsible? If not, are there situations where you may become financially responsible? Do you control and determine treatment? Under what conditions can you terminate the contract? Are you obligated to treat covered patients after termination? If so, for how long and at what fees? Will your name be marketed and advertised? How? Do you have prior approval? What are the terms of payment? If the company does not pay you or stops paying you, are you allowed to collect from the patient? Are you responsible for charges by another emergency treating dentist? Will you be subject to utilization review? If you must abide by it, will it compromise your professional judgment? Who owns and controls the company? What has been its track record? Does the company have a recoupment policy—that is, can the company do a retrospective 7 For AGD Constituent Use Only review of your records to ask for a refund for procedures performed deemed unnecessary? Dentists considering participation in an alternative delivery/payment system may wish to contact AGD HQ at [email protected] for the AGD’s contract analysis service, which is free to members. After receiving the analysis, dentists should share and/or review this information with their personal attorney and/or financial advisor to determine whether the new program will fit into their current dental practice. Additionally, the ADA also offers a similar program to members for a nominal fee. You may contact the ADA Contract Analysis Service at <http://www.ada.org/member/newdent/mancare.html>. However, priority is generally given to contracts that are sent through the state dental association. Capitation Programs: In this type of program, contracting dentists are paid a fixed amount, usually on a monthly basis, per enrolled patient or family. In return, the dentist agrees to provide a specific level of treatment or scope of benefits to the patients as necessary. Payment is based on the number of persons eligible for dental benefits during a payment period, regardless of whether the subscribers receive treatment. Under certain circumstances, subscribers may be responsible for a minimal surcharge or co-payment, usually for special services involving dental laboratory procedures, oral surgery and periodontal surgery. Subscribers may receive benefits only if treated by a contracting dentist. Once a provider is chosen, the patient may be treated by only that individual or facility for the length of the contract, often one year, except if a specific treatment in progress must be completed. Capitation programs protect the plan purchaser from the possibility that the cost of benefits may exceed projections by transferring the financial risk to the dentist, who is paid a set rate for the length of the contract. Contracting dentists are usually responsible for referrals and costs associated with specialty services or emergency care. Financial gain is realized only when actual treatment costs are below the projected levels. For this reason, it is not to the contracting dentists’ benefit if actual service costs exceed the level of capitation payments. In many cases, substantially more care is required in the early months of the program in order to establish a maintenance level of patient care. The participating dentist’s initial risk is that the capitation payment will not cover the cost of treatment delivered in this first period. A secondary risk is that this initial financial deficit may not be recovered if the patient changes providers or if the plan purchaser does not renew the contract. It is also possible that the rates of the renewed contract will be lower than the rates of the initial contract, thereby creating an incentive to limit treatment, to withhold certain services, or to provide less expensive treatment options to capitation patients. However, this practice could result in failure to provide necessary treatment. The aspects that seem to appeal to dentists who participate in capitation programs include predictable periodic income, the cost savings realized from not having to devote staff time and energy to completing claims forms (although some companies require encounter forms to track your utilization), and monitoring account collection. There is also the possibility that joining this type of program will increase the number of new patients, thereby creating a new source for patient referrals. 8 For AGD Constituent Use Only Some capitation programs require periodic reviews of patient records in order to evaluate and monitor services rendered. In some instances, contracting dentists have had to modify their record keeping systems in order to conform to the review requirements. Verification of patient eligibility must be ongoing and may additionally disrupt your normal office routine. Some practitioners feel that capitation programs deprive patients of freedom of choice and may interrupt already-established provider-patient relationships and treatment plans. In some cases, they may not allow adequate provision for specialist referrals and, under certain circumstances, the capitation dentist may be asked to perform specialty services he or she does not typically perform or he or she may be financially liable for the cost of specialty care. Capitation-Surcharge Programs: The Capitation-Surcharge Program model combines the fixed payment concept of a standard capitation program with a limited modified fee-for-service payment structure with surcharges allowed to be charged to the patients for certain procedures, for example, crowns and bridges. Often these surcharges can be quite low, intending to cover all or a portion of laboratory fees. If referrals are allowed, they may be limited to a specialist who also contracts with the capitation program. Joining a capitation program requires serious thought. When signing any contract, there are questions and issues to consider and be aware of, many of which should be answered by the contract. Capitation programs vary from: the amount of paperwork involved; the restrictions placed on the provider; the minimum amount of experience required to be enrolled; and the different number of plans within a program. Although most plans capitate between 30 and 45 percent of the collected premiums, there are plans that capitate around 60 percent. You should keep in mind that payment to the provider varies from plan to plan; some plans pay at the date of enrollment, while others pay after the first office visit. When joining a capitation program, shop around and choose the plan that best suits your needs. Dental Service Corporations: Dental service corporations account for a large percentage of the dental prepayment market with plans that usually include contractual agreements with dentists who agree to provide services to subscribers at pre-filed fees. Benefits in these programs are usually administered on a usual, customary, and reasonable (UCR) fee. The dental service approach provides benefits to subscribers in actual dental services, not as reimbursements based on scheduled dollar amounts for each service. Participating dentists must meet certain uniform requirements established by the corporation to ensure its fiscal stability. Contracting providers usually are required to file confidential listings of user fees for each procedure and may be subject to periodic in-office verification of those fees. These requirements allow the corporation to know the dentist’s usual fee in advance and aid the corporation in developing UCR programs. When fee filing is not required, the corporation identifies UCR fees from the actual charges submitted on claims. The participating dentist receives benefit payment directly from the service corporation and cannot charge the patient any more than the difference between the accepted filed fee and the plan-paid benefit. Of course, certain policies and procedures will differ when treatment is rendered by nonparticipating dentists, who are allowed to bill patients for any account balance, but patients may 9 For AGD Constituent Use Only be reimbursed at a lesser level. To be successful, a service benefit program must have a significant number of dentists within the state participating in the program. Contracting providers agree to cooperate in quality assurance programs, including routine and selective posttreatment reviews and binding arbitration by state and peer review committees. Some participating dentist agreements involve non-profit organizations, and require participating dentists to accept limited financial risk—for instance, in the event that the service corporation depletes its financial reserve, the provider may be required to complete treatment for the duration of the contract, even though compensation may be reduced or eliminated. Direct Reimbursement Programs: The direct reimbursement dental benefit program is a self-funded, freedom of choice benefits plan that eliminates the possibility that the plan sponsor will influence treatment decisions by reimbursing claims to the patient as a fixed percentage of the amount spent on dental care, regardless of the treatment category. Subscribers receive dental care pay for their treatment immediately and then submit a receipt and statement of service to their employers for direct reimbursement. Third-party carriers are rarely involved in the process. Since the direct reimbursement benefits model does not involve a middle-man, it benefits all parties involved by having the patient pay the dentist directly for services. This process is streamlined, easy to administer, and theoretically, considerably less expensive, with more dollars available for patient care. This type of plan is especially easy for plan participants to understand because it is based on actual dental expenses incurred. Another advantage of this model is that there is no need to delineate covered services, which in some cases may negatively influence treatment decisions and interfere in the provider-patient relationship. Patients are given the freedom to choose not only their provider but the type and extent of oral therapy they desire. In providing treatment, dentists are not limited by what services their patients’ plans cover. In addition, purchaser costs are limited by cost sharing levels, modest annual maximums and direct payment by patients. By not involving a third party, both the employer and the provider realize considerably lower administrative costs. A potential disadvantage exists in that depending on how the program is written, the patient may have to first pay the dentist and then be reimbursed by the employer. However, the employer has great flexibility in designing a direct reimbursement program and the ADA has extensive information available to help in this regard. Electronic Claims and the NPI Requirement: Electronic claims submission is a growing trend in the benefits industry. For the participating dentist, submitting claims electronically generally expedites processing and reimbursement by the insurer. Often, electronic claims may be submitted through your office’s practice management system or computer with an internet connection. If a dentist chooses to implement electronic claims processing, he or she must be aware of the requirements of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) associated with it. 10 For AGD Constituent Use Only HIPAA requires all “covered entities” to use a National Provider Identifier (NPI) for electronic transactions. HIPAA states that, “Providers who transmit health information in electronic form via standard HIPAA electronic transactions are considered covered entities.” All electronic claims submitted (since May 23, 2007) must include the provider’s NPI. The National Dental Electronic Date Interchange Council (NDEDIC) has posted detailed information on its website (www.ndedic.org) about NPI and HIPAA that is relevant to general dentists. Fee Schedule Programs: Under this benefit reimbursement model, participating dentists are required to provide services to subscribers at fees that may be below those most frequently charged in the community. Participants in this type of plan agree to accept the scheduled fees as payment in full and may not collect the balance from patients. Fee schedule programs are relatively inexpensive for group purchasers, may also be offered to individuals, and may expand the participating dentist’s patient base. They do not allow subscribers freedom of choice and may encourage selection of providers solely on the basis of cost. In addition, by limiting the choices of providers, fee schedule programs may interrupt already established provider-patient relationships and treatment plans. Some have claimed that since participating dentists may reduce fees in order to increase the patient base, this type of program may cause conflict between professional judgment and the need to generate revenue. Flexible Benefit Programs and Cafeteria Programs: Within the past several years, a number of corporations adopted flexible benefit packages, which give employees the ability to choose between cafeteria plans and flexible spending accounts. In the cafeteria-style plan, employees are given a specific dollar amount of benefits to “spend” on any combination of benefits. This option allows employers to maintain a certain level of benefits costs, while still meeting the specific health care needs of each employee. Frequently, when employees select benefits from a cafeteria-style plan, dental insurance is selected only if funds remain after selecting other options such as medical care, retirement plans, sick leave, disability, and vacation benefits. Another option in flexible benefit programs is the flexible spending account, in which employees may reduce their salaries providing their employers use those funds for selected service expenses approved in the Internal Revenue Service Code. General categories of allowed expenses include medical, child care and legal costs. Participants may apply deductions towards such items as medical expenses and co-payments. In the case of dental care, funds may be set aside to cover the year’s co-payment; or, if the employee does not have dental coverage, funds may be used to cover the year’s expected dental costs. Health Maintenance Organizations (HMOs): Health Maintenance Organizations (HMOs) deliver comprehensive health services, stressing preventive care, to a group of subscribers at a single premium. Since the HMO serves as both provider and insurer, it assumes the risk that the cost of treatment rendered may exceed the 11 For AGD Constituent Use Only premium paid by subscribers. This delivery system is often less costly to plan purchasers than traditional insurance packages. Purchasers pay a set premium to the HMO to cover their subscribers, who in turn select a primary care provider from the list of individual providers contracted by the HMO. The single premium per individual or family is designed to cover the cost of care to all subscribers, regardless of how often they use the plan. Providers are paid either a flat rate for each patient regardless of the amount of care provided, or are paid according to the number of patients seen in a given time period. Referral to specialists or hospitalization can be ordered only by the primary care provider. The principle economies perceived through this delivery system relate to reduced hospital days per annum for insured populations. Some critics express concern that HMOs may undertreat patients since they make the most profit by delivering less treatment. Some HMO managers claim patients often overuse services because they pay little or nothing for the care they receive. Some physicians formerly associated with HMOs report they felt pressured to give too few tests and too little treatment and were required to deal with administrators who tried to influence medical decisions. Some HMO subscribers claim that there is a long wait for appointments and that they can receive treatment from specialists only if they are referred by their HMO provider or if they personally pay the specialist’s bill. While the HMO concept is geared more toward medical care than dental care, some HMOs are including dental plans as a means to build their business. Because hospitalization is rarely a factor in the delivery of dental care, the HMO model is not believed to offer greater savings in the provision of dental care. Generally, under HMO dental plans, diagnostic, preventive and basic restorative services are provided at no charge to the patient. Depending on the plan’s design, patient surcharges, expressed as a dollar amount, may be imposed for more extensive services such as crowns, bridges, surgery, dentures and orthodontics. Under certain circumstances, dentistry can be delivered under an HMO-type model and often this is referred to as “managed care” (however, managed care can be found under a variety of other models as well). This type of managed care calls for a “personal” dentist to develop patient treatment plans, including any “specialty” services that may be needed, but can be delivered only if approved by the third-party carrier, and may be performed by a “specialty” dentist. Depending upon the plan, “specialty” services may include a variety of procedures: endodontics, oral surgery, periodontics, and IV sedation and general anesthesia. Frequently, orthodontic appliances and services are considered a completely separate category and are administered under a separate insurance rider with an individual lifetime maximum. Another category can be HMOs that employ salaried dentists. These closed panel systems are established when patients, eligible for services in a public or private program, receive services only at specific facilities by a limited number of providers. Often, the closed panel directly assumes the financial risk of providing care within the premium income of the plan, and receives compensation based on a fixed amount for each beneficiary, similar to a capitation plan. In other instances, closed panel participants are reimbursed through a salary, percentage of gross, fixed fee, or combination basis. Individual Practice Associations (IPAs): Individual Practice Associations (IPAs) consist of groups of practitioners, usually practicing individually, often with an administrator, which contract with a purchaser of dental benefits in a manner that is designed to be more economical than conventional delivery systems for both the 12 For AGD Constituent Use Only purchaser and group members. Involved dentists usually agree to provide treatment to eligible subscribers at fees below those most frequently charged in the community. IPAs are legal entities organized and operated on behalf of participating dentists for the primary purpose of collectively entering into contracts to provide prepaid dental services to enrolled groups. They are organized and operated on behalf of dentists or dental societies as a way to leverage their ability to compete in the dental benefits market. IPAs are similar to the capitation-risk pool model except that they pay providers solely from a risk pool. An IPA may contract directly with a group purchaser or with an insurance carrier for delivery of dental benefits. Generally, IPA dentists assume financial risk for the program and are reimbursed directly via the agreement with the purchaser. Participating dentists practice in their own offices and can also provide care to patients not covered by the IPA contract. Instead of assigning relative value systems to the procedures performed, each dentist in the association files claims, noting the usual fees charged for services provided to IPA subscribers. If program costs exceed premium income, participating dentists may receive less income than the actual value of the services performed. Insurance-Free Practices: A growing number of dentists are distancing themselves and their practices from dental insurance companies and proudly claiming to be “insurance-free.” This is an interesting and significant trend inasmuch as most surveys regarding the practice of dentistry point to the fact that most respondents report their number one problem is dealing with the dental insurance companies. The concept is being encouraged by consultants who are on the circuit giving reasons such as bureaucratic problems, excessive paperwork, payment delays, interference with treatment, fee restrictions, interference with the dentist-patient relationship, being kept “on hold” for excessive periods of time, inappropriate and unfair insurance company policies, lost forms, lost x-rays, comments such as “we never received your claim form”, etc. Additionally, patients also experience frustration in light of greater limitations, restrictions, and exclusions as well as stagnant annual maximums in the presence of significantly higher dental costs. Most dentists who take this step refuse to submit claims directly to the insurance company although they will fill out a standard claim form and give it to the patient. Most will not accept assignment, but rather make their financial arrangement directly with the patient who is solely responsible for the finances. This type of practice modality is not for everyone and all aspects of your practice should be examined before cutting ties with the carriers. Consultations with dentists who have moved in this direction or with consultants who are experts in this arena are appropriate. Managed Care: Managed care is a term for a concept that is continually evolving. Because of the differences between medicine and dentistry, medical managed care concepts do not always transfer well to the practice of dentistry. Managed care is a general term designed to affect cost containment. It often refers to capitation-type payment modalities, but may include modified capitation, HMOs, PPOs, or other provider discount systems. It may include the concepts of utilization review, utilization management, record audits, and/or fee limitations. Management Service Organizations (MSOs): 13 For AGD Constituent Use Only Management Service Organizations (MSOs) are a more recent entry into the dental health care delivery system. Under this structure, a third-party corporate entity purchases a dental practice and hires dentists as employees. The ADA is researching the implications of MSO dental models and will contact members employed through this system in order to learn more about it, how it works, and its impact on the doctor/patient relationship, as well as whether it interferes with the dentist’s use of professional judgment. While the answers are still unknown, many have expressed concern that these arrangements may focus primarily on financial elements and place too little emphasis on the practitioner’s professional judgment. Additional issues include the grievance process and the ability of the state dental board to revoke the license of a dentist who claimed to have been performing under the direction of an employer. The MSO model opens the door for non-dental ownership of the practice, which both the ADA and the AGD oppose. Preferred Provider Organizations (PPOs): The preferred provider organization (PPO) benefits model is a contracted plan under which contracting dentists agree to discount their fees as a financial incentive for patients to select their particular practices.* These individual dentists, most of whom have been solicited by carriers, agree to provide treatment to eligible subscribers at fees below those most frequently charged in the community. This serves as an incentive for patients and, in return, the carrier and sometimes the purchaser agree to promote the contracting dental facility to plan subscribers. These arrangements often feature priority claims service for patients being treated by contracting providers and sometimes include coverage for services not covered in many standard contracts. This benefits model offers eligible subscribers freedom of choice, but provides financial incentive—a discounted fee schedule—to encourage subscribers to seek care from a participating provider. Subscribers may elect to receive treatment from non-contracting providers, but will be required to contribute a greater co-payment since the insurer will pay these claims at a lower percentage. The PPO program allows participating health care providers to remain in traditional fee-forservice practice while still being able to compete for dental benefits dollars. While this benefit program typically does not require the dentist to assume additional financial risks, the contracting provider is subject to, and must abide by, utilization review or else leave the plan. An Exclusive Provider Organization (EPO) is the same as a PPO except there is no freedom of choice for subscribers. Subscribers must seek care from panel dentists to receive benefits. They are not eligible for financial benefits if they prefer to choose their own dentist. Table of Allowances/Fixed Benefit Programs: The table of allowance program specifies a maximum dollar benefit for each covered procedure, regardless of the fee charged. As a result, there is sometimes a difference between allowed coverage and the fee charged. Plans vary according to their provisions to adjust reimbursement rates for inflation and according to the determination of coverage for required procedures not included in the table. 14 For AGD Constituent Use Only The table of allowance model sets benefits in specific dollar amounts for all covered procedures. Benefits are payable only in amounts equal to or less than the fees specified in the table. Frequently, such plans do not automatically respond to fluctuations in the dentist’s fees and may result in an increase in the cost to subscribers. Also, since schedules are usually set in relation to the administrator’s calculation of community fees, subscribers may measure the fees charged against the benefits in the table and believe that the fees charged are inappropriate. In instances when allowances are set at levels that are high in relation to community fees, fees at the lower end typically rise to the level of the schedule, thereby giving less assurance that a reasonable degree of cost-sharing is maintained and that the determination of allowances for specific procedures may influence the course of treatment. Table of allowance plans are relatively simple and easily understood by subscribers. Usual, Customary, and Reasonable (UCR) Programs: Usual, Customary, and Reasonable (UCR) programs are dental benefit plans that determine benefits based on “usual, customary, and reasonable” fee criteria. The reimbursement percentage depends on the treatment category of care provided. UCR fees may vary greatly due to wide fluctuations in the demographic data (which may be based on national, regional, ZIP code or another demographic breakout) used, as well as due to a lack of regulation or consistency of the determination for the “customary” fee levels.* Before reviewing the specific aspects of a UCR program, it is important to understand the definitions of each term. These are outlined below. A usual fee is the fee that an individual dentist most frequently charges for a specific dental procedure. A customary fee is the fee level determined by the administrator of a dental benefits plan to establish the maximum benefit payable under a given plan for that specific procedure. A reasonable fee is the fee charged by a dentist for a specific dental procedure that has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances and therefore may differ from the dentist's usual fee or the benefit administrator’s customary fee. In the UCR dental benefits model, benefits are based on fees charged by the dental provider, but only to the extent that each fee is no greater than the maximum allowable fee as determined by the program administrator, based on procedural or composite fee data or other considerations. Most UCR programs provide a high level of benefits and permit the weighting of benefits to encourage preventive care while imposing a limit on the fees upon which benefits will be calculated. Since benefits are primarily based on fees charged, UCR programs often respond automatically to fluctuations in the cost of dental care. However, compared to other plans, UCRs can be more expensive for group purchasers to offer and administer and the complex definitions of UCR may make it difficult for subscribers to understand the benefit levels. Also, the design of the program may cause some subscribers to have more of a co-payment if their provider’s fees are determined to be above the UCR for that community. 15 For AGD Constituent Use Only III. How to Resolve Conflicts General Opening or building a dental practice is a difficult and laborious activity, and the process rarely becomes easier. As with others starting a business, the dental health care provider is required to fulfill a variety of roles, with each one having unique interests and priorities. Your responsibilities as an employer differ from your requirements as a small business owner and operator, which differ from your responsibilities as an involved citizen within your community, and so on. You are also a health care professional whose goal is to provide quality treatment to each patient and to build a successful practice. As you juggle the various responsibilities inherent in each of these roles, your patients may also call upon you to serve as the intermediary with their employer or insurance carrier in order to ensure that they receive the maximum benefits allowed under their dental insurance plans, while they contribute the lowest rate of co-payment possible. For many practitioners and their employees, this role produces the most stress and requires the most time. In fact, previous membership surveys have shown that members want the AGD to be actively involved in solving problems with third-party payment mechanisms. While there is no “quick fix” approach to resolving conflicts with third-party carriers, this chapter may help to reduce the frequency of these situations. On the following pages are descriptions of problems common to third-parties and sample draft responses to assist you in resolving these situations. You may also want to refer to Chapter 4, which lists relevant AGD policies and to Chapter 6, which contains additional information from the AGD’s Membership Survey and fact sheets to assist you in educating patients and resolving problems with carriers. AGD Headquarters has often successfully intervened on members’ behalf to resolve a variety of problems with third-party carriers. Successes include persuading an insurance company to change its policy and allow dentists to prescribe nicotine patches and persuading a self-funded plan to change its policy to allow general dentists to perform services that were previously identified as a specialty area. The AGD also played a key role in changing the placement of a fraud warning on one carrier’s Explanation of Benefits statement. A few years ago, the California State Society of Orthodontists announced a media campaign that would result in consumers bypassing general dentists as primary oral caregivers. Their consumer kit instructed parents on how to take impressions to determine whether their children needed orthodontic exams. After speaking with the AGD, their campaign was altered to encourage consumers to seek services from general practitioners as well as orthodontists. Most recently, the AGD and other organizations successfully compelled a clear aligner company to remove its onerous minimum patient quota requirement for use of its product. Make sure to keep AGD Headquarters informed of situations with third-parties. They are always interested in learning about constituent success stories, and can provide guidance and other assistance. 16 For AGD Constituent Use Only Self-Funded Programs: Be aware that the conflict resolution approaches suggested in this chapter may not always be successful, particularly in cases involving self-funded insurance programs. In this dental benefits model, rather than purchasing coverage from an insurance carrier, the employer or sponsoring entity assumes the role of insuring agency and incurs the financial risk of the program. Often an insurance carrier or third-party administrator may be retained to process claims and perform other administrative functions. Self-funded plans are regulated by the Employee Retirement and Income Security Act (ERISA) and are exempt from state regulations. As a result, the individual State Boards of Insurance can’t act on complaints against either a third-party administrator or the company offering the selffunded plan to its employees. In addition, some insurance companies that offer traditional insurance also serve as third-party administrators for self-funded plans. This sometimes causes confusion in determining where to refer a patient for investigation of a complaint. When in doubt, contact the claim office to determine if the plan is self-funded or if it is a group insurance policy. When a problem arises under a self-funded plan, the U.S. Department of Labor is the appropriate authority for investigating the patient’s written complaint. It is important to be aware that ERISA does not specify time limits for the payment of claims, but reasonably prompt payment is expected. In those cases where a self-funded program habitually delays payment for an unreasonable amount of time, you may receive payments more promptly by sending a letter of complaint to the employer or the third-party administrator. AGD Checklist for Resolving Problems with Carriers: Before consulting the suggested steps to resolve any particular situation, we suggest you review the AGD Checklist for Resolving Problems with Carriers, which appears on the next two pages. We also encourage you to communicate these guidelines to your membership by printing them in your constituent newsletter or by distributing them in response to member requests for assistance in resolving third-party conflicts. The Checklist was developed by the Dental Practice Council as a way to help individual members resolve third-party problems. Council members believe that it is best to handle most situations locally by having the dentist’s office staff work directly with the carrier. The Checklist calls for the dentist’s office staff to build a cooperative relationship with local carriers. A good working relationship can solve many problems, and the closer the practitioner and staff are to the carrier, the more effective they can be at resolving any difficulties. The Council also suggests involving the patient in the resolution process. The individual patient is most impacted by the carrier’s policies—he or she needs and wants the dental treatment and is ultimately responsible for payment. Also, the carrier is more likely to listen to the patient’s complaint about the policies of the dental plan than to respond to the objections of an outside party. 17 For AGD Constituent Use Only AGD CHECKLIST FOR RESOLVING PROBLEMS WITH CARRIERS Type of Insurance: ___ HMO ___ PPO ___ Capitation ___ Fee-for-Service (indemnity) I Specifically, what is the problem, what is your complaint and what is it that you would like the AGD to do for you? How would you like to see this case resolved? _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ _______________________________________________________________________ II Have you enclosed all pertinent correspondence and information? III Have you contacted the carrier in an attempt to resolve this case? A. Have you determined whether this is a contractual limitation? If so, what does the contract state? 1. Did you speak with a dentist or a clerk? Name __________________________________________________ Phone (_______) ________________________ Date _________________ a. 2. IV Did you record the person’s/persons’ name(s) and telephone number, the date of your conversation, and the concerns/decisions discussed? Is there someone in a position of higher authority that you should talk to? a. Did you write to the president and/or chairperson of the company? Have you asked the patient to intercede? A. Has the patient notified his or her employer, benefits manager, and/or union representative? 18 For AGD Constituent Use Only B. V Is an internal appeal process available? A. VI Do you have copies of that correspondence? (Make and keep copies of all correspondence) Has the patient used it? Have you notified the following organizations in the sequence shown below? A. Local dental society 1. Is peer review a viable option? B. State dental society 1. Do local relationships allow for direct intervention? C. State insurance commissioner 1. Is the carrier operating under a state issued certificate of insurance?* 2. Is it a self-funded plan regulated by ERISA?* D. American Dental Association’s Council on Dental Benefits E. Academy of General Dentistry’s Dental Practice Council 1. Do you agree to inform the AGD of any change in the disposition of this case, such as a resolution or withdrawal? 2. VII Do you agree to inform the AGD of any further communication on the part of the carrier, the patient, or yourself? Have you and/or your patient sought legal advice? A. Have you and/or your patient discussed the possibility of resolving the matter through the courts? *NOTE: A Certificate of Insurance is regulated by the State Insurance Commissioner and the State’s insurance laws. The patient may contact the department of insurance regulation or whatever regulatory agency exists for these purposes. 19 For AGD Constituent Use Only Self-Funded Plans are regulated by ERISA (the Federal Employment Retirement Income Security Act). Plan participants have a right to examine all insurance documents in the plan administrator’s office at no charge. Copies of documents can be obtained for which there may be a reasonable charge. If the claim for benefits is denied in whole or part, the plan administrator must provide a written explanation of the reason for the denial. The patient has the right to have the claim reviewed and reconsidered. There are steps that can be taken to enforce those rights. These include filing suit in a federal court or seeking assistance from the nearest area office of the U.S. Labor-Management Services, Department of Labor. Some concerns, such as coordination of benefits, may be appropriately communicated to the state insurance commissioner. AGD Dental Practice Council October 21 and 22, 2005 Complaint Reporting Form: The AGD has adapted the Complaint Resolution Form used by the ADA in its third-party problem resolution program in order to assist constituent dental care chairpersons in reporting local problems to the national organization. Upon being notified by a member that he or she is experiencing difficulty in satisfactorily resolving a complaint with a third-party carrier, you should first make certain that the individual has followed the AGD Checklist for Resolving Problems with Carriers and then determine what support you, as the Constituent Dental Care/Practice Chair, can provide. Once you determine that all possible avenues have been explored, you should copy and complete the following Complaint Reporting Forms and submit it, and all relevant background information, to AGD Headquarters. Staff will then review the situation and determine what future action is appropriate. You should also notify your state dental association about the problem. 20 For AGD Constituent Use Only AGD COMPLAINT REPORTING FORM Information Only; No Action Required: Yes ___ No___ Desire Assistance: Yes ___ No___ PROVIDER INFORMATION: Last Name First Name AGD Member # Region/State Office Phone ( ) ___ M.I. ____ Home Phone (_______)_______________________ INSURED INFORMATION (SUBSCRIBER): Last Name First Name ___ M.I. ____ Address _____________________________________________________________________________ City ___ State Date of Original Claim: __ ZIP Phone (_______)__________________ __ Social Security # __________________________ PATIENT (IF DIFFERENT FROM SUBSCRIBER): Last Name First Name Relationship to Subscriber: Self (1) City State Spouse (2) ZIP M.I. _____ Child (3) Other (4) ____ Phone (_______)_________________ Please submit, with this form, an authorization for release of patient information that complies with the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and is signed by the patient or an authorized representative, prior to the release of any information related to the patient or this claim, including, but not limited to charts, x-rays and other records of treatment, to the Academy of General Dentistry. Patient information that is not accompanied by a HIPAA compliant authorization for release of information, signed by the patient or an authorized representative, shall not be accepted or considered. 21 For AGD Constituent Use Only EMPLOYER INFORMATION (Please complete the following information if it is known): Name: ____________________________________________________________________________ Address ___________________________________________________________________________ City ________________________ State ZIP Benefits Contact: ___________________________________ Phone (_______)_________________ Phone (_______)_________________ THIRD PARTY INFORMATION: Policy # _____________________________________ Name of Insurance Company: __________________________________________________________ Address _____________________________________________________________________________ City _______________________ State Contact Person: Zip Phone (______)__________________ Phone (______)___________________ Plan Type _____ NATURE OF COMPLAINT—CHECK ALL THAT APPLY: Lost/Misplaced Claim (LMC) Dentist Consultant Review (DCR) Lost/Misplaced Radiographs (LMR) Unqualified Claim Reviewer (UNR) Unauthorized ADA Code Change (UCC) Coordination of Benefits (COB) UCR Fee Dispute (UCR) Explanation of Benefits (EOB) Delay/Lack of Response (DLR) Treatment of Relative (TOR) Assignment of Benefits (AOB) Denial of Claim (DEC) Other (OTH): __________________________________________ NATURE OF THE PROBLEM: In your own words, describe the details of the problem. If more space is needed, attach additional sheets. Include all supporting documents: letters, claims forms, explanation of benefits (EOBs), remittance advice, etc. ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ 22 For AGD Constituent Use Only EFFORTS TO RESOLVE THE PROBLEM (Describe what you have done to resolve this conflict): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Forward to: The Academy of General Dentistry Director, Dental Practice Advocacy 211 East Chicago Avenue, Suite 900 Chicago, IL 60611-1999 ------------------------------------------------------------------------------------------------------------------------------Date Entered Complaint Deposition Date Resolved 23 Region/State _________ For AGD Constituent Use Only Pre-Approach: As your Constituent’s Dental Care/Practice Chair, you must communicate effectively with thirdparty carriers. When assisting members, it is always best to have a copy of all documents related to the situation before initiating any activity. The following pre-approach letter, designed by the Dental Practice Council, requests the carrier to explain the specific cause for the benefit denial/reduction. This letter may assist you in gathering pertinent facts and allow you to objectively analyze the situation. If you are already aware of the specific reason for the denial/reduction, you need not use this letter but rather may move onto another, more appropriate text. Draft of a Pre-Approach Letter Date Name of Carrier Executive Title Name of Carrier Complete Street Address City, State, ZIP Dear (Insert Name): A member of our organization, Dr. (Name), has shared with us your (denial/reduction) of benefits for his/her patient M/M (Name). We are writing to you on behalf of Dr. (Name) to request the specific reason for this decision. In order for us to gain some valuable information, which might assist us in resolving this problem for our member, we would appreciate a response from you as soon as possible, hopefully by (date). Sincerely, Your Name Constituent Dental Care/Practice Chair Academy of General Dentistry 24 For AGD Constituent Use Only Benefit Exclusion Clauses: AGD membership surveys have indicated that 70.2 percent of responding general dentists reported that they have been denied payment of benefits for providing certain services. When a member of your constituent advises you that a carrier’s policy includes benefits exclusion clauses, your best approach may be to direct a polite and informative letter to the carrier pointing out the policy’s shortcoming. Be certain to send copies of the letter to the member, to the Director, Dental Practice Advocacy, at the AGD, and the individual at the state dental association who is responsible for dental care issues. A sample letter follows. Draft Response to Benefit Exclusion Clauses Date Name of Carrier Executive, Title Name of Carrier Complete Street Address City, State, Z Dear (Insert Name): One of our members, Dr. (insert name), has expressed concern that (insert carrier’s name) dental insurance policy as held by (insert employer’s name) will reimburse plan participants for (specify type of treatment, such as endodontic, orthodontic, periodontic, etc.) dental treatment only when it is rendered by a (insert type of specialist, such as endodontist, orthodontist, etc.). We are attaching copies of the correspondence our member has provided us, which includes notification that (insert carrier’s name) will not pay for this treatment unless it has been performed by a specialist. It would seem to us that the patient is being penalized for going to a general dentist who felt sufficiently qualified to deliver this therapy without having to refer the case to a specialist. Select text as applicable to the situation. There are many areas of the country that have few, if any, dental specialists. According to a recent survey of Academy of General Dentistry (AGD) members, nearly (insert appropriate figure from the chart that appears at the end of this chapter) percent of responding general dentists perform this type of treatment. By limiting the availability of these services, the price of this treatment may greatly increase as fewer dentists are available to render these services, or some individuals requiring treatment will find it extremely difficult to locate dentists to perform the necessary procedures. It is the nature of the state regulatory agencies to license general dentists to perform all phases of dentistry and to give them the discretion to determine when a case should be referred to a specialist. Referral should be at the discretion of the treating dentist. As an organization of 35,000 general dentists which fosters continuing education for general dentists, the AGD encourages its members to continually update their knowledge so they can effectively deliver patient treatment. We urge you to change this discriminatory policy which has the potential to create so much dissatisfaction for the subscribers to this dental benefits plan. We look forward to hearing from you soon. Sincerely, Your Name Constituent Dental Care/Practice Chair Academy of General Dentistry 25 For AGD Constituent Use Only Limitation of Benefit Based on UCR: When patients claim that they have been overcharged because your fee for providing treatment exceeds the amount covered by their dental plan, the best response is usually to advance patient education. Make certain that the form your practice uses to record patients’ medical histories clearly states that any difference between the fee charged and the benefit paid is due to limitations in the individual’s employer’s benefit contract, and that any unpaid funds are the patient’s responsibility. When a patient notifies you that his or her benefit is lower than your fee for service, explain in writing that the treatment plan developed and followed was based on what was in the individual’s best interest for maximum improved or maintained oral health care, not on the basis of what services or fees were approved under the patient’s dental insurance program, which frequently provide less than optimal benefits. Inform your patient that fees are based on practice overhead, the treatment plan selected and the time involved in providing appropriate dental care. Note that it is in no one’s best interest to compromise recommended treatment solely to accommodate a third party’s maximum benefit allowance, which may barely be adequate, much less optimal. Indicate that you are willing to review the treatment plan and the rationale for your professional judgment regarding this case and how it might differ from the third-party carrier’s position. Let your patient know that you base your treatment decisions upon your professional judgment, regardless of whether the individual is covered by an insurance plan. The insurance carrier may be basing its fees on out-of-date information or it may not have taken into account certain local factors that may affect the fees for various services. 26 For AGD Constituent Use Only Draft Response to Limitation of Benefit Based on UCR Date Patient Name Complete Street Address City, State, ZIP Dear (Insert Name): You recently contacted my office to let us know that your dental insurance benefit program provides coverage for (specify type of treatment) at a rate lower than the fee you have been charged. I would like to take this opportunity to explain to you why my fee for this service differs from what your carrier may have called the “usual, customary and reasonable” fee. My professional philosophy is to develop and follow treatment plans that are based on what was in your best interest for maximum improved or maintained oral health care. My treatment decisions are not based on what services or fees are approved under your dental insurance program. In fact, it is not uncommon for dental insurance plans to provide their subscribers with less than optimal benefits. My fees are based on three elements—the cost of overhead to operate my practice, the cost of delivering the treatment that you and I have selected, and the cost of the time involved in providing you with this care. You do not benefit if the recommended treatment is compromised for the sole purpose of accommodating a third party’s maximum benefit allowance. If your dental insurance carrier has a qualified dentist on staff who reviews claims, I would be happy to discuss your case with this individual. I would hope that after reviewing the treatment plan and specifics of your case, the dental consultant would be better informed to take a stand regarding this case. You should be aware that insurance carriers frequently base their determinations of “usual, customary and reasonable” fees on out-of-date information or they may not take into account certain local factors that affect the fees for various services. In any case, you may be assured that for all of my patients, I base my treatment decisions upon my best professional judgment, not upon the patient’s third-party carrier’s dental benefits plan. Please contact me with the name and telephone number of your carrier’s dental consultant in the event that you would like me to review the specifics of your case with that individual. Sincerely yours, Your Name 27 For AGD Constituent Use Only When a Carrier Changes the Original Treatment Code: AGD membership surveys have indicated that 75 percent of our members perform non-surgical periodontics. Many carriers have become increasingly concerned about the expense of honoring claims for periodontal care, while practitioners remain concerned with the ability to properly provide the care their patients require. In recent years, carriers have begun to seek more specific information from dentists regarding periodontal therapy. They question methods of treatment and sometimes change treatment codes in order to pay benefits at a lower level. In fact, some dentists provide therapeutic periodontal procedures and are paid at prophylaxis fees. Codes for periodontal disease vary according to the level of disease a patient may have and the provider’s method of treatment. Providers need to be certain that they understand the proper use of each code to ensure that patients receive their entitled benefits and the necessary and appropriate treatment. One way to lessen the possibility of claims being questioned and codes being changed is to complete the narrative portion on the patient’s claim. When a member advises you that a carrier has denied a patient’s benefit by changing the treatment code, advise him or her to direct a polite and informative letter explaining how the diagnosis was reached and how the patient’s treatment relates to the code’s definition. It may also be helpful to provide the carrier with copies of the patient’s chart, X-rays, and drawings to support the provider’s diagnosis and treatment. Both the AGD and the ADA recommend reporting all instances of downgrading of codes by carriers to the state insurance commissioner and to the patient’s employer. Draft Response to a Carrier Changing the Original Treatment Code Date Name of Carrier Executive Title Name of Carrier Complete Street Address City, State, ZIP Dear (Insert Name): One of our members has expressed concern because (insert carrier’s name) has denied a patient proper reimbursement by changing the code for periodontal disease treatment. The Academy of General Dentistry, an organization of approximately 35,000 general practitioners, fosters continuing education for general dentists and encourages them to continually update their knowledge so that they can be more effective in rendering patient treatment. (Insert a paragraph about the code’s definition and how it specifically relates to the patient’s diagnosis and treatment.) While we are sensitive to your desire to control health care expenditures, we believe that by changing codes, you are misleading the patient and second-guessing the doctor’s diagnosis. I urge you to review 28 For AGD Constituent Use Only this estimate and revise it to cover the appropriately prescribed and delivered periodontal disease treatment. Sincerely, Your Name Constituent Dental Care/Practice Chair Academy of General Dentistry Denial of Benefits When Treating Family Members: Many insurance companies have policies against reimbursing subscribers for treatment costs when care is rendered by a family member, claiming that health care professionals do not bill their spouses, parents, siblings or children. While this is not always the case, and while the patient should be allowed the freedom of choice to select a dental health care provider regardless of a familial relationship, the fact remains that the contractual provisions of many third-party plans disallow payment of benefits when there is a familial relationship between the provider and patient. AGD membership surveys have indicated that 21.1 percent of dentists have reported denial of benefits when treating a family member. While plan subscribers pay premiums for the dental benefits, their freedom of choice is often limited by the exclusion of situations when care is provided by a member of the family. There is little chance that an appeal of this policy will be successful if this exclusion is stated in the plan’s contract or provisions. An appeal may be successful if a benefits policy is changed and the insurer or carrier fails to notify subscribers. Denial of Payment for Covered Procedures per the Contract Language: Nearly every dentist whose patients have dental insurance has experienced the situation when a third-party insurer denies payment for a procedure that the provider felt should have been covered under the language of the contract. An AGD membership survey indicated that 70.2 percent of all respondents experienced this problem. If this should happen to you, bear in mind that insurance companies typically don’t deny payment arbitrarily—if you’re willing to investigate the case, chances are you’ll discover the reason for the differences of opinion. No one is immune from human error, be they your employees or the employees of an insurance company. When a claim is rejected, the first thing you should do is review the information available to you. Review the limitations of the contract. Make certain that you submitted the correct procedure code number. Determine whether the patient has run out of dental benefits for the year. Verify that your office followed the instructions established by the insurance carrier, such as making certain that written explanations were provided for those procedures requiring a narrative account. Once you determine that correct submission procedures were followed and that the patient was not at the limit of his or her benefits, call the carrier to determine why the claim was denied. Discuss the case with someone other than the claims processor, preferably the dental consultant or someone from the provider relations department. Offer the facts about why you believe the 29 For AGD Constituent Use Only treatment provided was covered under the benefits contract. Follow the steps outlined in the AGD Checklist for Resolving Problems with Carriers. Your chances of affecting change likely depend upon the responsiveness of the carrier. Keep in mind that pre-determination of benefits could help minimize this problem. 30 For AGD Constituent Use Only Professional Courtesy: Unfortunately, cases involving one dentist making disparaging remarks about another dental professional occur all too frequently. These situations are probably among the most frustrating since they indicate a lack of professional courtesy and behavior from other practicing dentists and may serve as evidence in a malpractice lawsuit. In any case, the most effective approach calls for you to be professional, practical, and correct in your expectations, as well as courteous in your approach. You may be able to successfully resolve this type of incident by following these key steps: Contact the individual who made the remark directly. Establish dialogue and suggest talking about it over lunch. Contact your local or state dental association to have this adjudicated through an ethics committee, since speaking disparagingly of colleagues could be considered a breach of ethics. Seek legal redress through an attorney. This will create bad feelings, but it can be effective in ending the problem. In addition, the ADA’s Principles document states in Advisory Opinion 4-C that dentists are under obligation to report to “appropriate reviewing” agencies any “gross or continual faulty treatment by other dentists.” This does not mean a dentist may harshly criticize a colleague to the public nor does it allow a practitioner to suggest that a non-specialist also providing general specialty services is unqualified to do so. Loss of Radiographs: An AGD membership survey indicated that 52.2 percent of respondents reported loss of radiographs as one of the problems they encounter with third-party carriers. There is little an individual practitioner can do to prevent a third-party carrier from misplacing the radiographs of subscribing patients. As a result, the most effective precaution you can take is to always send duplicate copies and maintain the originals of all radiographs in your own files. Some practitioners take what is known as “double pack” radiographs in order to ensure that they have a second copy. Others take two pictures or have a duplicating machine in the office to make certain that they’re able to satisfy the needs of the third-party carrier and maintain the integrity of their own files. This is especially important because in the event of a lawsuit, radiographs would be important part of the provider’s defense. Of course, doubling up on radiographs as a preventive measure involves additional expense. Since it’s impossible to predict which patients’ dental insurance plans will require radiographs, it’s next to impossible to know which patients should undergo “double pack” radiographs. Many practitioners are not comfortable going through the efforts and cost of duplicating all radiographs or find it difficult to charge patients for the fees associated with meeting the requirements of their dental benefits plans. Yet few third-party carriers have policies that reimburse providers for the cost of supplying duplicates of radiographs, and although it should not be the case, the provider most frequently bears the cost of duplicating radiographs. However, many practitioners prefer this option to risking the loss of original radiographs by submitting them to third-party carriers. 31 For AGD Constituent Use Only With the onset of digital technology, duplicates may become less of an issue. Digital radiography is a contemporary modality with increasing use that will likely enable you to send copies of X-rays while maintaining the original. Misdirected Payment of Benefits: In situations when payment was issued directly to the patient despite the assignment of benefits, most third-party payers will acknowledge and correct the mistake, although in some states they may not be obligated to do so. In cases when the benefit check is issued to the patient by mistake, contact the patient, indicate the situation and request that payment be remitted to your practice. If the patent refuses to cooperate, turn the account over for collection and notify the patient’s employer. If a particular carrier consistently takes an excessive amount of time to process claims or often loses them, you may wish to send future claims by certified mail. However, you should remember that unless a written agreement exists to the contrary, the third-party carrier’s responsibility is to the patient, not the provider. Periods of Patient Ineligibility: Many dental insurance benefit programs delay patient eligibility for coverage for a certain time period initially after enrollment. Other programs allow only basic services for a given time frame, and require a longer period of participation in the plan before covering other services, such as periodontal care. Other plans have been known to require patients to complete an “evidence of insurability” form, which the carrier deems is a necessary and sound business practice that prevents patients from engaging in “adverse” selection, or in the selection of dental coverage only during the time period that they expect to need extensive treatment. Third-party carriers use each of these mechanisms to control or contain the costs of providing care to their subscribers. There is little the provider can do to counter the carrier’s restrictions on subscriber eligibility. Pre-determination: The acts of submitting a treatment plan for pre-determination or of pre-certifying a patient’s eligibility do not guarantee payment of benefit. It’s critical that the health care provider have a thorough understanding of the nuances, and commitments, associated with each of these terms. The ADA’s official definitions of each term are outlined below; however, it should be noted that their use by third parties is not consistent. Pre-certification: Confirmation by a third-party payer of a patient’s eligibility for coverage under a dental benefits program. Pre-determination: An administrative procedure that may require the dentist to submit a treatment plan to the third party before treatment is begun. The third party usually returns the treatment plan indicating one or more of the following: patient’s eligibility, guarantee of eligibility period, covered services, benefit amounts payable, application of appropriate deductibles, co-payment, and/or maximum limitation. 32 For AGD Constituent Use Only Reduced Benefits for Non-contracting Providers: Nearly 64 percent of the respondents to an AGD membership survey reported diminished payment of benefit because they were not a participating provider; this problem has shown a great increase in frequency over the past two years. While more providers are participating in a wider variety of dental benefits plans, at some time every practitioner experiences the situation where payment of benefits are reduced because you are a non-contracting provider. In these instances you must contact the patient who is responsible for paying any balance due. Upon welcoming a patient into your practice, you should consider asking the patient to read and sign a statement agreeing to assume financial responsibility for any treatment, regardless of the amount of benefit paid by a third-party carrier. Two-Tiered Reimbursement Systems: The AGD opposes separate fee levels to specialists providing the same or similar services as general practitioners. When a general dentist performs a procedure that he or she is licensed to do, reimbursement should be the same as that provided to a specialist. Two-tiered reimbursement practices reaffirm a caste system within the profession, implying that specialists are worth more simply because they’re specialists. Yet patients also suffer under two-tiered reimbursement systems. If a patient is reimbursed at a lower rate when being treated by a general dentist instead of a specialist, the carrier is suggesting that the subscriber should receive care from a specialist, even though treatment by the general practitioner may be more reasonably priced. If the subscriber is not aware that the reimbursement will be less if care is rendered by a general practitioner, then the individual receiving care is penalized because although the patient is paying a set premium regardless of who delivers care, the reimbursement level for care rendered by the general dentist will be lower than that given for specialist care. Unfortunately, two-tiered reimbursement systems are a problem common among general dentists. Over 52 percent of the respondents to an AGD membership survey reported diminished payment of benefits because they were general dentists, not specialists. Changing these types of practices requires a great deal of carefully coordinated communication, but often the outcome is worth the effort. For instance, the AGD recently was successful in convincing a dental insurance plan in the northeast to change a two-tiered endodontic reimbursement practice. Upon being advised by a member that a carrier is engaged in a twotiered reimbursement system, your best approach may be to contact the carrier and detail the detriment of such a practice. Be certain to send copies of the letter to the member advising you of the situation, the Chairperson of the Academy’s Dental Practice Council, the AGD Director of Dental Benefit Programs and Dental Practice, and the individual at the state dental association who is responsible for dental care issues. A sample letter follows. 33 For AGD Constituent Use Only Draft Response to Two-Tiered Reimbursement Practices Date Name of Carrier Executive Title Name of Carrier Complete Street Address City, State, ZIP Dear (Insert Name): One of our members has expressed concern regarding a recent practice by (insert carrier’s name) of a (specify type of treatment, such as endodontic, orthodontic, periodontic, etc.) reimbursement program that pays (insert type of specialist, such as endodontist, orthodontist, etc.) more than general dentists for rendering identical services. The Academy of General Dentistry strongly believes that fees should be determined by the complexity of the procedure, not by whether a practitioner specializes in a particular area of dentistry. I am certain that you are aware that there is a hierarchy of dental services associated with any specialty area. General dentists often perform services at the lower end of the hierarchy and refer the more complex cases to specialists. Generally, the fees of a general dentist also tend to be at the lower end of the hierarchy. If the general dentist is qualified to deliver the same treatment as a specialist, it is in neither your best interest nor the patient’s best interest to reimburse the specialist at a rate higher than the general dentist. You should be aware that your policy is also detrimental to your plan’s subscribers, who may not be aware that the reimbursement will be less if care is rendered by a general practitioner. The subscriber to your plan pays a set premium regardless of who delivers care. It is unfair to penalize the subscriber for electing to receive care by a general dentist. In addition, by advocating that patients receive care from specialists in order to maximize their benefits under your program, you are suggesting that the subscriber receive care from a specialist, who is almost certain to charge more than a general dentist for providing the same treatment. As a result, you are ultimately increasing the sum of the reimbursements payable to participants in your plan. I feel confident in presuming this was not your intent. We ask that you review this two-tiered reimbursement program and the inequities it creates for all parties involved. Sincerely, Your Name Constituent Dental Care Chair Academy of General Dentistry 34 For AGD Constituent Use Only Unreturned Referrals: These situations rate among the most frustrating experiences, since they indicate a lack of respect for another professional’s practice. Most dentists typically refer patients in need of more specialized care to other providers with whom they’ve established a professional rapport. Referring relationships are established on the basis of respect for another provider’s skill and reputation. For such a relationship to remain strong, both providers rely upon continued goodwill and follow-up communication as necessary. Few dentists receiving referred patients for more specialized care would neglect to contact the referring practitioner to discuss the outcome of a case as this could have a negative impact on future referrals. However, if you have referred a patient to another dentist and have not received a follow-up report, contact the dentist by telephone and inquire into the specifics of the case, such as what treatments were performed and whether there were any problems or if the patient experienced any pain. It’s likely that your colleague had planned to contact you regarding this case, but that time had elapsed faster than expected. If you are frequently required to make follow-up phone calls to a specific practitioner, or if it is routinely a negative experience, you may wish to discontinue referring patients to that provider. Utilization Reviews: Utilization review is a procedure usually undertaken by a third party or an entity that has been created expressly for this purpose. The goal of utilization review is to determine how often individual dentists are performing certain procedures and then compare the frequency of these procedures with other dentists who have also had this determination done. Usually the review, done with the aid of computers utilizing submitted dental insurance forms, will determine for example how many crowns are done per 100 patients, or how many scaling and root planings are done per 100 patients. These ratios are then averaged and the dentists are compared to each other. Carriers may arbitrarily determine a cut-off point beyond which any dentists whose ratios for specific procedures fall beyond this are deemed “outliers.” In other words, the carrier has determined that they perform these particular procedures far in excess than do their fellow dentists. In some instances, the carriers will contact the dentist and discuss with him or her the reasons why they may be doing certain procedures to a much greater degree than their colleagues. Subsequent to this, the dentists may be “encouraged” to bring the number of these procedures performed into line with what the carrier has deemed acceptable. If the dentist is a contract dentist and has not complied with the wishes of the carrier with regard to cutting back on the number these specific procedures performed, he or she may be asked to leave the network. If the dentist is not in the network, prior authorization may become a requirement. Still other carriers may insist on a review of the patient records and if appropriate and adequate (as determined by the carrier) substantiation for the performance of these procedures is not found in the records, the carrier may determine that much of the treatment rendered was unnecessary and may ask for financial reimbursement. Often, unwittingly, dentists agree to abide by these rules and to allow the carriers to enforce arbitrary regulations regarding utilization review by signing a contract without carefully examining it or understanding it. It is important, as with any contract, that you carefully review and evaluate the conditions and rules of a contract prior to signing the contract. 35 For AGD Constituent Use Only If you have questions regarding any contract, you may contact the ADA contract analysis service or the AGD’s Director of Dental Benefit Programs and Dental Practice. If you are contacted by a member who is notified by a third-party carrier who claims that the practitioner performs a specific procedure with much greater frequency than other local practitioners, your best response is to contact the carrier, communicating the ADA’s position that practitioners ignore these letters. However, it is important to send copies of the letter to the member advising you of the situation, the chair of the AGD’s Dental Practice Council, the AGD Director, Dental Benefit Programs and Dental Practice, and the individual at the state dental association who is responsible for dental care issues so the main offices of the AGD and the ADA can coordinate their responses. A sample letter follows. Draft Response to Utilization Reviews Date Name of Carrier Executive Title Name of Carrier Complete Street Address City, State, ZIP Dear (Insert Name): One of our members has advised us that they have received utilization review correspondence from you which indicates that (he/she) performs (specify type of treatment, such as endodontic, orthodontic, periodontic etc.) treatment with a greater frequency than do other practitioners in the (insert city name) area. You are no doubt aware that the Academy of General Dentistry and the American Dental Association agree that statistically based utilization reviews should in no way be used to determine acceptable norms of clinical standards of dental practice since these letters present little more than an incomplete and broadbased sketch of the full picture which must be examined in order to determine treatment. In addition, both organizations remain firm in their positions that dentists receiving such letters should not alter their practice patterns. We urge (insert name of carrier) to reconsider the impact of these utilization review letters, which remain an irritant to practicing dentists. Sincerely, Your Name Constituent Dental Care Chair Academy of General Dentistry 36 For AGD Constituent Use Only Draft Response to Misinterpretation of Coordination of Benefits Date Name of Carrier Executive Title Name of Carrier Complete Street Address City, State, ZIP Dear (Insert Name): One of our members, Dr. (name), has expressed concern over a situation involving a patient with two dental insurance policies. This patient, (insert name), has primary dental insurance through (his/her) employer, (name), and secondary coverage through (name). Pre-estimations were sent to both carriers in order to determine the level of benefits that could be expected for treatment costing $(amount). The patient’s primary carrier estimated payment of benefit at $(amount), and the secondary carrier communicated to the patient a predetermination of benefits in the amount of $(amount). When treatment was completed and billing was done, the primary carrier paid $(amount), as stated in their predetermination of benefit. Your company, however, limited its payment of benefit to $(amount), downgrading benefits and claiming there was a duplication of benefits. It appears that there is some misunderstanding regarding the different meanings of duplication of benefits and coordination of benefits. In fairness to the patient, you may want to establish a coordination of benefits when patients have two dental benefit plans. This policy could note that in these cases, coverage under both plans should be coordinated so the patient receives the maximum allowable benefit from each one. The aggregate benefit should be more than that offered by either plan alone, but not such that the patient receives more than the total charges for the dental services received. Accordingly, (insert patient name) should be entitled to receive reimbursement based upon your preestimate, which was developed with full knowledge of the amount that would be paid by the primary carrier. I urge you to reconsider this case and to rightfully base your payment of benefit on your predetermination of benefits. Such an action would be consistent with the acceptable positions governing coordination, not duplication, of benefits. Dr. (name)’s concern will be communicated to our Dental Practice Council for discussion at its next meeting. I would appreciate hearing from you as soon as possible so I may share your response with its members. Thank you. Sincerely, Your Name 37 For AGD Constituent Use Only Draft Response to Denial of Benefit for Sealants Date Name of Carrier Executive Title Name of Carrier Complete Street Address City, State, ZIP Dear (Insert Name): One of our members, Dr. (insert name), has expressed concern that your fund’s insurance program will not reimburse plan subscribers for the application of pit and fissure sealants. It is your position that participants who take advantage of (customize text as appropriate, i.e. “two dental exams and cleanings per year with fluoride treatments for children”) provide adequate protection as long as the patient regularly practices proper oral hygiene. Your denial of benefits implies that the use of fluoride negates the need for sealants, which may wear off and require resealing. It would appear that the designer of your dental plan may not have the latest information on the cost effectiveness of sealants. You should know that sealants were first developed through dental research in the 1950s and became commercially available in the early 1970s. They can be highly effective in protecting treated tooth surfaces from caries and are a very reasonably priced component of preventative oral health care. In addition to preventing new caries from forming, sealants can stop existing cavities from further progression because they prevent nutrients from reaching the cavity. While both fluoride and sealants offer protection against caries, their benefits are complimentary and the application of one does not preclude the value of the other. In addition, the U.S. Surgeon General’s Report on Oral Health has identified sealants as a key component in reducing caries among pediatric populations. Sealants benefit everybody. I urge you to review your benefits program and to revise it to allow payment of benefit for the application of sealants. Surely the outcome, the improved health of your employees and lower long-term benefit payouts, is advantageous to everyone involved. Dr. (insert name)’s concern will be communicated to the Dental Practice Council of the Academy of General Dentistry, and will be placed on the agenda for their next meeting. I would appreciate hearing from you as soon as possible so I may share your response with its members. Thank you. Sincerely, Your Name 38 For AGD Constituent Use Only Draft Response to Rejection of Claim for Overpayment Date Name Address City, State, ZIP Dear Name: Dr. _______, a member of our association, has forwarded a copy of your ______ (date) correspondence to us. __________ is seeking a refund from Dr. ______ to recover an alleged “overpayment” in the amount of $_______, which ___________ claims was made by mistake. On behalf of Dr. ________, the Academy of General Dentistry’s 35,000 members respectfully reject your position. It is widely held that an insurance carrier is not entitled to recover an overpayment made to an innocent third-party creditor when: a.) the payment was made due solely to the insurer’s mistake, b.) the mistake was not induced by a misrepresentation of the third-party creditor, and c.) the third-party creditor acted in good faith without prior knowledge of the mistake. See Prudential Ins. Co. of America v. Couch, 376 S.E. 2d 104 (W.Va Sup. Ct. of App. 1988); Time Ins. V. Fulton-DeKalb Hosp. Auth., 211 Ga. App. 34, 438 S.E. 2d 149 (Ga. App. 1993); City of Hope Med. Ctr. V. Superior Court, 8 Cal. App. 633, 10 Cal. Rptr. 2nd 465 (Cal. App. 2 Dist. 1992); Lincoln Nat. Life Ins. V. Brown Schools, 757 S.W. 2d 411 (Tex. App. 1988); Federated Mutual Ins. Co. v. Good Samaritan Hospital, 191 Neb. 212, 214 N.W. 2d 493 (Neb. Sup. Ct. 1974). Here, regardless of whether amounts paid by _________ constitute an overpayment, ________ knew its own policy payment provisions and alone made the decision of paying said amounts that it now alleges were beyond its responsibility. Dr. ________ made no misrepresentations, had no knowledge or notice of ______’s alleged mistake, extended valuable services, was not unjustly enriched, and simply had no reason to suspect that the payments for services rendered were in error. _______ was the entity that treated the situation and was in the best position to have avoided it. Furthermore, Dr. _______ has no recourse relative to the patient. Under the circumstances, Dr. _________ has no obligation to return the alleged “overpayment” and declines to do so. Please confirm that no further efforts will be made to recover said alleged “overpayment” from Dr. ________. I look forward to hearing your reconsideration. Sincerely, Your Name Chair, Constituent, etc. cc: Dr. (Name) 39 For AGD Constituent Use Only Draft Response to Denial of Benefit for Dentist Writing a Tobacco Cessation Prescription Date Name of Carrier Executive, Title Name of Carrier Complete Street Address City, State, Zip Dear (Insert Name): The Academy of General Dentistry, an organization of 35,000 general practitioners, fosters continuing education for general dentists and encourages them to continually update their knowledge so that they can be more effective in rendering patient treatment. One of our members, Dr. (insert name), has expressed concern that your fund’s insurance program will not reimburse plan subscribers for tobacco cessation prescriptions written by dentists. According to a patient, reimbursement for this type of health improvement care is only available in cases when the prescription is written by a medical doctor. This unnecessarily restrictive policy may actually be causing your firm to pay higher benefits in the long term, as several recent studies have proven that employees who continue to use tobacco products are more susceptible to illness and absence, and they frequently must be treated for very serious, even life-threatening, diseases. The number of dentists writing prescriptions for such products is on the rise. In fact, many pharmaceutical firms are promoting the dentist’s role in tobacco cessation support through programs geared to the profession, to pharmacists and to the general public. The U.S. Department of Health and Human Services (Canadian Ministry of Health) is directly involved with the major dental organizations in having the dental profession more involved in tobacco cessation programs because a large percentage of the public is likely to visit the dental office at least once each year. The American Cancer Society estimates that each year, there are more than 30,000 new cases of oral cancer and more than 8,000 deaths caused by oral cancer. About 75 percent of these cancers can be attributed to smoking and/or alcohol use. Early diagnosis is often possible with oral cancers, and by supporting the tobacco cessation efforts of your employees; you can reduce their risks of becoming one of these statistics. In addition, you greatly reduce insurance claims submitted in response to diseases brought on by tobacco use. I urge you to review your benefits program and to revise it to allow equal benefit for tobacco cessation treatment, regardless of whether the prescribing practitioner is a physician or dentist. Surely the outcome, the improved health of your employees and lower long-term benefit payouts, is advantageous to everyone involved. A copy of this letter is being directed to the attention of (insert name), an administrator of your account, so the two of you can review and update your policy. Dr. (insert name)’s concern will be communicated to the Dental Practice Council of the Academy of General Dentistry, and will be placed on the agenda for their next meeting. I would appreciate hearing from you as soon as possible so I may share your response with its members. Thank you. Sincerely, Your Name Constituent Dental Care Chair Academy of General Dentistry 40 For AGD Constituent Use Only AGD Checklist for Resolving Problems with Dental Products and Material and the AGD Checklist for Resolving Problems with Dental Equipment Before consulting the suggested steps to resolve any particular situation, we suggest you review the AGD Checklist for Resolving Problems with Dental Products and Material or the AGD Checklist for Resolving Problems with Dental Equipment, which appear on the next four pages. We also encourage you to communicate these guidelines to your membership by printing them in your constituent newsletter or by distributing them in response to member requests for assistance in resolving third-party conflicts. These Checklists were developed by the Dental Practice Council as a method to help those members experiencing problems with dental equipment, products, and/or material. While AGD staff is advised of these problems only occasionally, 61.2 percent of the respondents to an AGD membership survey reported experiencing these types of problems in the last year, and 18.7 percent expressed interest in having the AGD help them resolve these situations. Of those members reporting these problems, 70.4 percent discussed it with a sales representative and 51.9 percent contacted the manufacturer. Over three-quarters of all respondents (75.2 percent) reported that they were able to resolve the problem satisfactorily. The Checklists call for the dentist to review some basic information, and it is hoped that the practitioner will be able to resolve these situations through the simple, easy-to-follow steps outlined in each Checklist. 41 For AGD Constituent Use Only AGD CHECKLIST FOR RESOLVING PROBLEMS WITH DENTAL PRODUCTS AND MATERIAL I Have you followed the manufacturer’s directions for using the product? Yes A. No Were there any indications that there might be a problem with using this material? If yes, please specify what they were. Yes B. No Is the product still within its recommended shelf life? Yes No II Have you checked the user’s manual or product information guide, which may contain helpful “troubleshooting” suggestions? III Write down the brand and product name, UPC and product expiration information (if applicable), your account or customer identification number, the original invoice, and a description of the problem on a separate piece of paper and attach it to this form. IV Contact the supplier/manufacturer from whom you originally purchased the product. A. Factually describe the problem you’ve experienced and its implications for your patients. B. Communicate your dissatisfaction with the results and politely request either a refund or replacement. Offer to return any remaining stock of the product in question to the company. (If a considerable amount is involved, you may want to ask that it be sent COD or that they reimburse you for shipping costs). Determine if you need a prior authorization number—some companies will refuse deliveries if they do not have a preauthorization number on the return address label. C. If this individual cannot offer an acceptable solution, ask to speak with someone higher up in the firm. At this point, you may want to put your request in writing, making certain to maintain a professional and business-like tone and including copies of any supporting correspondence that might help this individual resolve your complaint. 42 For AGD Constituent Use Only V VI Send copies of the above materials to the AGD and Dan Meyer, DDS, Director of Scientific Information, ADA Council on Scientific Affairs. Request ADA support and involvement. You may opt to report the problem you experienced to MedWatch, a voluntary reporting program operated by the Food and Drug Administration. Health professionals are encouraged to report adverse events and product problems to MedWatch, which tracks these types of complaints regarding products and materials that are under the purview of the FDA. Contact MedWatch by calling 800.FDA.1088 or online at www.fda.gov/medwatch. *PREVENTIVE TIPS* Maintain copies of invoices and product usage materials. Determine the age of the product—it cannot perform at optimum levels if it is beyond its useful shelf life date. 43 For AGD Constituent Use Only AGD CHECKLIST FOR RESOLVING PROBLEMS WITH DENTAL EQUIPMENT I Have you followed the manufacturer’s recommended maintenance schedule? Yes A. No Have there been previous indications that there might be a problem with the equipment? Yes B. No How old is the equipment? _____ Years _____ Months Has it recently been moved or undergone any physical disturbance? Yes II No C. Check the power switch, inline fuses, electrical plug, and circuit breaker. D. For air and water problems, make certain that filters and traps are clean and unblocked. Have you checked the user’s manual and followed its recommended “troubleshooting” suggestions? Yes No III Jot down the brand name, model number, your account or customer identification number, the original invoice, and a description of the problem on a separate piece of paper and attach it to this form. Locate the warranty and determine if the item is still covered. IV Contact the supplier/manufacturer from whom you originally purchased the product. A. Factually describe the problem you’ve experienced and its implications for your patients. B. Communicate your dissatisfaction with the results and politely request a refund, a replacement, or a free service call. If you want to return the product to the company, ask to ship it COD or request reimbursement for your shipping costs. Determine if you need a prior authorization number—some companies refuse deliveries that do not have a pre-authorization number on the return address label. 44 For AGD Constituent Use Only C. If this individual cannot offer an acceptable solution, ask to speak with someone higher up in the firm. Follow up on that conversation with a memorandum outlining the discussion. Keep the tone of your letter professional and business-like and include copies of any supporting correspondence that might help this individual resolve your complaint. V Send copies of the above materials to the AGD and Michael Lynch, DMD, PhD, Director of Scientific Affairs, ADA Council on Scientific Affairs. Request ADA support and involvement. VI You may opt to report the problem you experienced to MedWatch, a voluntary reporting program operated by the Food and Drug Administration. Health professionals are encouraged to report adverse events and product problems to MedWatch, which tracks these types of complaints regarding products and materials that are under the purview of the FDA. Contact MedWatch by calling 800.FDA.1088, or online at www.fda.gov/medwatch. *PREVENTIVE TIPS* Develop an interoffice maintenance schedule and list the responsibilities of each staff person. Determine what needs to be done daily, weekly, monthly, and annually. Maintain copies of original invoices, warranties, maintenance agreements and service bills. Determine the age of the equipment—if it’s old and frequently breaking, it’s time to replace it. 45 For AGD Constituent Use Only IV. Working Within Organized Dentistry General The AGD, in every aspect of its operation, strives to ensure that member dues dollars are applied judiciously to unique member benefits. The AGD is not interested in duplicating those programs and services available through other segments of organized dentistry. As a result, while some of the information reported here is relative to programs and services available through the ADA, it’s important to realize that the AGD has historically worked within organized dentistry in order to affect changes that are beneficial to the general dentist. The AGD is also skilled at being able to maximize on the opportunities available elsewhere within the profession. In direct response to problems experienced by members, the AGD’s Dental Practice Council has developed the AGD Checklist for Resolving Problems with Carriers, which appears in Chapter 2. In addition, AGD staff continues to assist members by working with contacts in other segments of organized dentistry in order to educate third-party payers and benefit plan purchasers in regards to the inequities present in their benefit plans. These coalitions have successfully resolved individual problems, and they also minimize or eliminate similar problems from occurring in the future. The AGD also helps members by providing our constituent officers with the tools and training necessary to keep them effective in intervening on behalf of the general dentist. Our goal is to empower you to resolve most situations locally, which is usually more appropriate and effective than trying to resolve these problems nationally. Of course, resources are available from other sources, and a number of valuable sources are available through the ADA. Highlighted on the following pages are some resources available from other members of organized dentistry. CDT The ADA’s CDT states that the codes and their descriptions are not subject to interpretation. It is the ADA’s opinion that the uniform use of language will provide an effective mechanism for communication among dentists, patients and third-parties. Maintaining the CDT as the standard should eliminate incorrect reporting of procedures, which has been advocated in certain continuing education courses. Barring the code from interpretation also protects practitioners from having codes changed by insurance carriers. The CDT is an ongoing review process and revisions will be written as deemed necessary. Selecting a Dental Benefits Plan This brochure, available through the ADA’s Council on Dental Benefit Programs, provides assistance in designing a dental benefit program. A brochure on the direct reimbursement benefit model is also available. Either of these resources may be helpful if you are contacted by an individual or company seeking information prior to developing an employee benefit plan. Your State Dental Association or Local Society 46 For AGD Constituent Use Only AGD leaders must be active within component and constituent dental societies. The best ways are to work within your state or local dental association and to volunteer on committees and get the job done. Many times Constituent Dental Care Chairs work closely with their state dental association to resolve general dentists’ problems or provide guidance in dealing with third-party problems. Peer Review The peer-review process is designed to benefit the patient, the provider, and the third-party carrier. Through this process, the dental profession reviews and resolves problems or misunderstandings regarding dental treatment that the provider and patient have been unable to resolve. Most peer review committees are comprised of at least three members who have volunteered to serve as impartial mediators. These individuals review the appropriateness or quality of care and in some instances, the cost of treatment. Their goal is to resolve any situation in a manner that is satisfactory to all involved parties, without requiring legal involvement. The recommendation of the peer review committee is conveyed to the provider and patient, and their decisions are final. Specific information on the process and procedures of your state’s peerreview committee are available through your state dental association. 47 For AGD Constituent Use Only V. Current AGD Advocacy Policies General The AGD’s policies are directed by the best interest of our general dentist members, while attempting to balance the views and needs of other areas of the profession. Before any AGD policy is developed and recommended to the AGD’s House of Delegates (HOD), AGD staff members research the issue, consider the pros and cons and, if appropriate, discuss it with peers at other, similarly-impacted organizations. Most advocacy issues are then referred to the AGD’s Dental Practice Council and/or the AGD’s Legislative & Governmental Affairs (LGA) Council. The policy recommendations of the council(s) are then referred to the AGD’s Board of Trustees or HOD, as appropriate, for consideration and voting. Advocacy Issues and the AGD’s Positions As the Dental Care/Practice Chair within your constituent, you serve as ombudsman for your colleagues—therefore, it’s imperative that you understand the relevance and impact of any issue that might affect the dental profession or the general practitioners’ right to practice. In order to be effective, you must first be aware of the AGD’s policies regarding a variety of advocacy issues. This chapter highlights the AGD’s stance on the following topics: 48 For AGD Constituent Use Only Table of Contents ADVOCACY POLICIES 2010-11 TABLE OF CONTENTS Accreditation and Recognition of Non-Specialty Areas ............................................................. 55 ADPAC ......................................................................................................................................... 56 ADPAC donation on dues statement ........................................................................................ 56 Advertising of Credentials ............................................................................................................ 56 Advertising of Credentials ........................................................................................................ 56 Advocacy Fund ............................................................................................................................. 56 American Dental Association ...................................................................................................... 56 Advertising campaign, no AGD position on............................................................................. 56 Liaison with .............................................................................................................................. 56 Requirement by AGD for membership in ................................................................................. 56 Anesthesiology .............................................................................................................................. 57 Cost of providing benefit .......................................................................................................... 57 Training availability .................................................................................................................. 57 Annual Meeting ............................................................................................................................ 57 ADEA, report to House by Legislative and Governmental Affairs Council ............................ 57 Contracts ....................................................................................................................................... 57 Contract analysis service........................................................................................................... 57 Dental Anesthesiology .................................................................................................................. 58 Dental Auxiliaries......................................................................................................................... 58 Advanced Dental hygiene Practitioner Position Statement ...................................................... 58 Courses in expanded duties for ................................................. Error! Bookmark not defined. Dental team concept .................................................................................................................. 58 Duties which will not perform to be defined ............................................................................ 58 Office personnel manuals ......................................................................................................... 58 Perform under direct supervision of general dentist ................................................................. 59 Recruitment strategies ............................................................................................................... 59 Salaries ...................................................................................................................................... 59 Training, education, and utilization of ...................................................................................... 59 Dental Practice ............................................................................................................................. 60 Amalgam, position statement supporting.................................................................................. 60 Uses for, procedures must be publicly disclosed .................................................................. 60 ANSI MD 156, AGD representative on .................................................................................... 61 Appropriate charges made for administrative work .................................................................. 61 Benefit coverage for dental surgery performed in office .......................................................... 61 Biophosphonate therapy............................................................................................................ 61 Bleaching trays, license should be required for fabrication of.................................................. 61 Child’s first visit to dentist, position on .................................................................................... 62 Claims, prompt payment of....................................................................................................... 62 Closed panel, opposed to .......................................................................................................... 62 Code of procedures, endorsed by AGD .................................................................................... 62 Consultant, ground rules for claims denial ............................................................................... 63 Co-payment and overbilling, waiver of .................................................................................... 63 Corporate Guidelines and Mandates ......................................................................................... 63 Date of manufacture of dental equipment and devices ............................................................. 63 49 For AGD Constituent Use Only Dental health education for the public ...................................................................................... 64 Dental hygienists, authority of State Boards of Dental Examiners ........................................... 64 Dental Implants ......................................................................................................................... 64 Dental insurance plan to include all facets of dentistry ............................................................ 64 Dental materials to be used in government-funded dental care programsError! Bookmark not defined. Dental products, materials, and medications, opposed to bans on the use of ........................... 65 Dental research, public funding for .......................................................................................... 65 Dentistry's position on a National Health Program ................................................................... 65 Dentist's right to collect a larger fee from patient ..................................................................... 65 Diagnosis and supervision needed for dental treatment ............................................................ 65 Diagnostic tests, dentists’ right to prescribe and perform ......................................................... 65 Environmental “best management” practices ........................................................................... 66 Evidence-based dentistry .......................................................................................................... 66 Definition of ......................................................................................................................... 66 Use of.................................................................................................................................... 66 Fees, adjustment of ................................................................................................................... 66 Fees; i.e., usual, reasonable, customary: definition of .............................................................. 66 First Dental Visit Timing and Establishment of the Dental Home (AAP Policy Proposal) ..... 67 Flexible Spending ..................................................................................................................... 67 Fluoridated public water supplies, public funding for .............................................................. 67 Fluoride in water supplies and toothpaste, position statement .................................................. 67 Freedom of choice provider ...................................................................................................... 67 Health care reform .................................................................................................................... 68 Health care reform criteria ........................................................................................................ 68 Issue priorities for government funding .................................................................................... 69 Licensing................................................................................................................................... 69 Criteria for eligibility ............................................................................................................ 69 Uniform standards for........................................................................................................... 70 Voluntary/Temporary Licensing .......................................................................................... 70 Manpower problems ................................................................................................................. 70 Medically compromised dental patients ................................................................................... 70 Disclosure of relevant information ....................................................................................... 70 Policy statement on treatment of .......................................................................................... 70 Medically indigent, support programs for................................................................................. 72 Medicare, amendment to reimburse dentists for rendering same service as a physician .......... 72 Nutrition and oral health ........................................................................................................... 72 Oral Conscious Sedation, position statement ............................................................................ 73 Parameters of care, ADA .......................................................................................................... 73 Parameters of care, criteria for .................................................................................................. 73 Preferred Provider Organizations ............................................................................................. 74 Prepayment plans ...................................................................................................................... 75 Bill payer system .................................................................................................................. 75 Exclude certain contract language ........................................................................................ 75 Include all phases of preventive dental services ................................................................... 76 Structuring of dental prepayment programs ......................................................................... 76 Public information available to public of dental office safety .................................................. 76 Resource-Based Relative Value Scale ...................................................................................... 76 Rights of employers to provide health care benefits ................................................................. 77 School curricula – oral health education ................................................................................... 77 Soft drink consumption/pouring rights contracts ...................................................................... 77 50 For AGD Constituent Use Only Supervision, definitions of for dental hygienists and other dental auxiliaries .......................... 77 Surgeon General's Report on Oral Health ................................................................................. 78 Implementation plan ............................................................................................................. 78 Third party mechanisms ............................................................................................................ 79 ADA's role in problems with ................................................................................................ 79 Claim contested by dental consultant of ............................................................................... 79 Considerations in deliberating dental health insurance programs ........................................ 79 Consultant of, should make no representation to patient regarding dentist's service or fee . 79 Diagnostic imaging ............................................................................................................... 79 Differentials in levels of reimbursement in .......................................................................... 80 Fee Determination ................................................................................................................ 80 Fee schedules based on utilization reviews considered arbitrary ......................................... 80 Guidelines for handling members’ problems with ............................................................... 80 Not to interfere with dentist's diagnosis and treatment ......................................................... 81 Overpayment recovery practices .......................................................................................... 81 Participation should not be contingent upon participation in government regulated programs81 Reduction/denial of dental benefits must be signed by licensed dentist............................... 81 Regulated by law or state governmental agency .................................................................. 82 Tissue biopsy ............................................................................................................................ 82 TMD policy statement .............................................................................................................. 82 TMJ ........................................................................................................................................... 83 Tooth numbering system........................................................................................................... 83 Untoward responses to products, materials, and medications................................................... 83 Workforce, adequacy of present dental workforce ................................................................... 83 Work force issues, position statement....................................................................................... 84 Dental Consultant......................................................................................................................... 84 Coalition to restore deduction for student loan interest ............................................................ 84 Must be a licensed dentist ......................................................................................................... 84 Dental Education.......................................................................................................................... 84 Deduction of interest paid on student loans .............................................................................. 84 Dental schools, support state funding for.................................................................................. 84 Formal academic process leading to a degree or certificate ..................................................... 85 Four-year curriculum, support of .............................................................................................. 85 Liaison consortium.................................................................................................................... 85 Licensure ................................................................................................................................... 85 Dental Laboratory Techniques .................................................................................................... 86 Dental Materials ........................................................................................................................... 86 Purchasing decisions ................................................................................................................. 87 Dental Practices............................................................................................................................ 87 Open elections and nominations for officers ............................................................................ 87 To be owned and operated by licensed dentists ........................................................................ 88 Dental Students ............................................................................................................................ 88 Financial assistance to, that restricts choice of geographical location of practice .................... 88 Loan program for ...................................................................................................................... 88 Recruiting highly qualified students ......................................................................................... 88 Requiring dental students to repay government capitation loans made to schools ................... 89 Denturism ..................................................................................................................................... 89 Direct Reimbursement .................................................................................................................. 89 Definition of .............................................................................................................................. 89 Promotion of ............................................................................................................................. 89 Dues .............................................................................................................................................. 89 51 For AGD Constituent Use Only Assessment................................................................................................................................ 89 Enteral Conscious Sedation ......................................................................................................... 90 Federal Services ........................................................................................................................... 90 Benefits for military personnel and their dependents ............................................................... 90 Salary reimbursement for military dentists ............................................................................... 90 Special pay for uniformed services ........................................................................................... 91 Fees ............................................................................................................................................... 91 Adjusted for complying with governmental regulations ........................................................... 91 General Dentist ............................................................................................................................. 91 Continued competency.............................................................................................................. 91 Creed of..................................................................................................................................... 91 Coordinate and manage dental health ....................................................................................... 92 Definition of .............................................................................................................................. 92 Parity with physicians in all remuneration ................................................................................ 93 Primary dental care provider, defined ....................................................................................... 93 Primary entry point into dental care system.............................................................................. 93 General Practice Residency Program .......................................................................................... 93 Commission on accreditation urged to require that directors of GPR's be general dentists ..... 94 Geriatric Care ............................................................................................................................... 94 Health Maintenance Organizations (HMO’s) ............................................................................ 94 Providing funds for HMOs ....................................................................................................... 94 Health Planning ........................................................................................................................... 94 Organized dentistry to provide input for ................................................................................... 94 Support to repeal Health Planning Act ..................................................................................... 94 HIV ............................................................................................................................................... 94 HIV-infected patients, policy on ............................................................................................... 94 HIV testing of dental personnel ................................................................................................ 95 Statement on disclosure and infection control .......................................................................... 95 Hospital Dentistry Privileges........................................................................................................ 95 Implants ........................................................................................................................................ 95 Pre-doctoral education .............................................................................................................. 96 Infection Control Measures Urged .............................................................................................. 96 Infectious Waste ........................................................................................................................... 96 State and government regulation .............................................................................................. 96 Insurance, Malpractice ................................................................................................................. 97 Legislation .................................................................................................................................... 97 Access to dental care ................................................................................................................. 97 Incentives for dentists to practice in underserved areas ....................................................... 97 Legislative agenda for providing .......................................................................................... 98 AGD opposes limiting political or PAC contributions ............................................................. 99 Air Force Assistant Surgeon General, Rank of ......................................................................... 99 Cash method of accounting, not accrual ................................................................................... 99 Community Health Centers..................................................................................................... 100 Deduction for member dues .................................................................................................... 100 Dental Lab Disclosure............................................................................................................. 100 Federal Trade Commission ..................................................................................................... 100 FTC's efforts to pre-empt state laws re corporate ownership.................................................. 100 General Practitioner's role as gatekeeper for oral health......................................................... 101 Government relations manager ............................................................................................... 101 Government subsidized health care programs ........................................................................ 101 Guidelines for dealing with state legislation ........................................................................... 101 52 For AGD Constituent Use Only Indigent population, AGD as a voice for the .......................................................................... 102 Language interpretation at provider’s expense ....................................................................... 102 Legislative or regulatory mandates with inadequate scientific basis ...................................... 102 Link between periodontal disease and low birth-weight babies ............................................. 102 Luken Lee Amendment, endorsement of ADA's position ...................................................... 102 Managed care, AGD’s legislative priorities regarding ........................................................... 103 Mandating national licensure .................................................................................................. 104 Mandating preferred provider organizations........................................................................... 104 Military dentists, special pay and incentives for ..................................................................... 104 National Practitioner Data Bank ............................................................................................. 104 NIDCR .................................................................................................................................... 105 Nitrous oxide inhalation sedation ........................................................................................... 105 Prohibiting latex use without documented scientific evidence ............................................... 105 Protect dental insurance as a fringe benefit ............................................................................ 105 Public disclosure of information in National Practitioner Data Bank..................................... 105 Public Health Service Surgeon General .................................................................................. 106 Sales tax on professional services - AGD opposition ............................................................. 106 State over federal regulation of the dental profession............................................................. 106 Student Loan Interest Deduction ............................................................................................ 106 Tax credit in states with reimbursement rates below 75th percentile ...................................... 106 Tobacco Cessation Treatment ................................................................................................. 106 Tobacco settlement earmarked for health care ....................................................................... 107 Veterans Administration Dental Director ............................................................................... 107 Water quality during routine dental treatments should be appropriate ................................... 107 Licensing..................................................................................................................................... 107 Limited to dentists and dental hygienists ................................................................................ 107 Licensure .................................................................................................................................... 107 By credentials ......................................................................................................................... 107 Limitation of Practice ................................................................................................................. 108 Malpractice Insurance and Litigation ....................................................................................... 108 Defending their capabilities to render dental procedures ........................................................ 108 Mandated Health Benefits ......................................................................................................... 108 AGD policy on ........................................................................................................................ 108 National Health Program, Dentistry’s Position on ................................................................... 109 National Practitioner Data Bank ............................................................................................... 109 OSHA .......................................................................................................................................... 109 AGD efforts to control regulations relating to infectious waste control ................................. 109 AGD influence in adopting guidelines.................................................................................... 109 AGD supports the ADA’s position on OSHA’s anticipated rule on Workplace Safety & Health ................................................................................................................................................ 110 Worker safety regulation, opposition ...................................................................................... 110 Patient Records ........................................................................................................................... 110 Confidentiality of .................................................................................................................... 110 Pediatric Dentistry ...................................................................................................................... 110 Defined.................................................................................................................................... 110 Peer Review Committees ............................................................................................................ 110 For general dentists ................................................................................................................. 110 PSROs (Professional Standards Review Organizations) ........................................................ 111 Quality control review by ....................................................................................................... 111 Seek general practitioner representation on ............................................................................ 111 Post Graduate Training.............................................................................................................. 111 53 For AGD Constituent Use Only Availability for all recent graduates ........................................................................................ 111 Public Information ..................................................................................................................... 112 Monitoring dental health messages to the public .................................................................... 112 Radiographs ................................................................................................................................ 112 Dental assistants must be properly trained to use ................................................................... 112 Submission to insurance carriers ............................................................................................ 112 Salaried Dentists ......................................................................................................................... 112 Sedation ...................................................................................................................................... 113 Adequate facilities for teaching .............................................................................................. 113 Teaching of, at the undergraduate and CE levels.................................................................... 113 Smoking ...................................................................................................................................... 113 AGD position on use of Tobacco............................................................................................ 113 Specialty License Laws............................................................................................................... 113 Specialty Listings ........................................................................................................................ 114 State Board of Dentistry ............................................................................................................. 114 Sterilization ................................................................................................................................. 115 Procedures ............................................................................................................................... 115 Surveys ........................................................................................................................................ 115 Of dental schools, annually ..................................................................................................... 115 Table of Allowances ................................................................................................................... 115 Acceptable reimbursement mechanism .................................................................................. 115 54 For AGD Constituent Use Only POLICIES Accreditation and Recognition of Non-Specialty Areas 2005:5-H-7 “Resolved, that the AGD adopt the following position regarding the accreditation and recognition of non-specialty areas of general dentistry: AGD Position on the Accreditation and Recognition of Non-Specialty Areas The AGD supports excellence in general dentistry and the pursuit of professional development through lifelong learning. Advanced education should meet independent standards so that the education is valid and provides the framework for excellent patient care. General dentistry is not just treating patients – it is being the educated gatekeeper of oral health so that the patient is provided with all the available options for treatment. The knowledge of when to treat and when to refer, and to whom, is the responsibility of the general dentist. The general dentist’s emphasis is on primary care. They guide patients to efficient, cost effective treatment while maintaining continuity of care. AGD supports the responsibility of the Commission on Dental Accreditation (CDA) to develop accreditation standards for all formal education programs in dentistry, whether they are in an ADA-recognized specialty, in general dentistry or in a non-specialty area of general dentistry. This is not changing the scope of practice for general dentists and dental specialists, nor is it adding new specialties. If non-specialty areas that provide formal advanced education can seek accreditation then the public will benefit. The general dentist is the coordinator of care and as such should be able to inform the patient of all available treatment options. The general dentist should have access to education in all areas of dentistry, including advanced education programs and continuing dental education. The specialist is a partner in dental treatment that is dependent upon patient referral from a general dentist. If general dentists have had additional education and training they are able to provide better patient care, treatment planning and know better when to refer to a specialist or another general dentist. This will strengthen the profession. It is not as important an issue that the public understand the scope of practice between practitioners as it is that they understand how oral health affects their overall health. Clear messages about why it is important to see the general dentist twice a year would be powerful messages to the majority of the public who are interested in their health. Whether the public sees a 55 For AGD Constituent Use Only specialist or a general dentist should be on the recommendation of their general dentist The ADA is uniquely poised to promote the image of modern dentistry to the public. It is not the role of the ADA to make patients aware of how to select a specialist – that is the role of the referring general dentist. The ADA should focus on getting the public to the dentist and in working within the legislative arena to see that access to care is improved. As CDA accredits advanced education programs in general dentistry, the ADA should consider mechanisms for recognizing board certification in general dentistry areas, including the American Board of General Dentistry.” ADPAC ADPAC donation on dues statement *87:52-H-7 RESCINDED Advertising of Credentials Advertising of Credentials 2008:314R-H-7 “Resolved, that the AGD adopt Announcement of Credentials to the Public: A Position Paper as its policy on the announcement of its FAGD and MAGD credentials.” Advocacy Fund 2009:315R-H-7 “Resolved, that the AGD create an Advocacy Fund.” American Dental Association Advertising campaign, no AGD position on 98:19-H-7 “Resolved, that the AGD take no formal position on the ADA’s institutional advertising campaign and accompanying assessment.” Liaison with *76:34-H-1 RESCINDED Requirement by AGD for membership in 56 For AGD Constituent Use Only 79:15-H-6 REVISED HOD 7/99 “Resolved, that it shall continue to be AGD policy to encourage membership in the American Dental Association, the Canadian Dental Association, or the National Dental Association.” Anesthesiology Cost of providing benefit 2002:29-H-7 “Resolved, that the Academy of General Dentistry believes patients with physical, developmental, emotional, or medically compromising conditions may require sedation/general anesthesia in private office, hospital, or surgical center settings for the safe and effective treatment of dental disease and/or injury, and be it further Resolved, that sedation and/or general anesthesia and related facility costs for the treatment of dental disease and/or injury in these patients should be a covered benefit in all group medical benefit policies and Medicaid.” Training availability 90:54-H-7 "Resolved, that the Academy of General Dentistry work with the American Dental Association and the American Dental Education Association to recommend that dental schools and hospital-affiliated teaching institutions establish anesthesiology programs so that dentists seeking in-depth education in anesthesiology will have such training available." 94:14.2-H-7 "Resolved, that educational opportunities be available so that general dentists will have adequate opportunity for training in dental anesthesiology in order to provide optimum pain and anxiety control for the public." Annual Meeting ADEA, report to House by Legislative and Governmental Affairs Council 94:22.2-H-7 "Resolved, that the Legislative and Governmental Affairs Council annually report to the Academy of General Dentistry's House of Delegates on the activities of dental schools and other organizations as they relate to the political concerns of general dentistry." Contracts Contract analysis service 88:47-H-7 2008:110-H-7 AMENDED HOD 2008 “Resolved, that Policy 88:47-H-7 be amended so that it reads: “Resolved, that the Academy of General Dentistry offer to its members a contract analysis service, and be it further 57 For AGD Constituent Use Only Resolved, that members be encouraged to seek the advice of their own attorney before deciding to sign a contract, and be it further Resolved, that the Dental Care Council develop means to educate Academy of General Dentistry members about the ramifications of provider contracts.” Dental Anesthesiology 94:14.1-H-7 RESCINDED HOD 2007 2007:302-H-6 “Resolved, that the HOD Policy 94:14.1-H-7, which recognizes anesthesiology as a specialty, be rescinded. 94:14.1-H-7 Resolved, that the Academy of General Dentistry supports the recognition of dental anesthesiology as a dental specialty” Dental Auxiliaries Advanced Dental hygiene Practitioner Position Statement “Resolved, that the AGD adopt the Position Statement on the Advanced Dental Hygiene Practitioner (ADHP) Concept.” 2008:322-H-7 Dental team concept 86:30-H-7 "Resolved, that the Academy of General Dentistry supports the dental team concept as the best approach to providing the public with quality comprehensive dental care, and firmly supports direct supervision of the practice of dental hygiene, and be it further Resolved, that this policy be conveyed to the American Dental Association, the American Dental Hygienists Association, and state and provincial boards of dental examiners, and be it further Resolved, that Policy #85:25-H-7 be rescinded." Duties which will not perform to be defined 73:23-H-10 "Resolved, that those states permitting expanded duties by dental auxiliaries define those duties which dental auxiliaries will not be permitted to perform in compliance with individual state dental practice acts." Office personnel manuals 58 For AGD Constituent Use Only 77:10-H-6 RESCINDED Perform under direct supervision of general dentist 73:24-H-10 "Resolved, that all duties performed by any dental auxiliary must be done under the direction and control of the dentist and that he or she be directly responsible for the actions of his or her auxiliaries performing those duties." Recruitment strategies 91:48-H-7 "Resolved, that the Academy of General Dentistry believes that its individual members can make a significant contribution to resolving the dental auxiliary shortage by attempting to recruit potential dental team personnel, and be it further Resolved, that the AGD play a key role in solving the dental auxiliary shortage by: 1. Encouraging AGD members to recruit dental auxiliaries each year, using materials provided by the ADA. 2. Educating AGD members to properly manage dental auxiliaries through: a. b. c. d. a request that the AGD editor publish an appropriate article in Impact. a request that the Council on Annual Meetings and International Conferences establish a course on this subject Suggesting to the AGD Foundation to offer an appropriate practice management course showing dentists how to properly manage and therefore retain dental auxiliaries. Asking AGD constituents to publish appropriate articles on this subject, tailored to local needs." Salaries 77:9-H-6 RESCINDED Training, education, and utilization of 73:25-H-10 "Resolved, that definite educational requirements be instituted for the proper training of dental auxiliaries in expanded duties and the AGD should study existing ADA approved programs to determine the appropriate educational requirements." 74:13-H-11 "Resolved, that in the training, education and utilization of dental auxiliaries for the purpose of assisting the dentist in providing high quality 59 For AGD Constituent Use Only dental care through performance of expanded functions, it shall be the recommendation of the Academy of General Dentistry that such auxiliaries be permitted to perform under the direct supervision of the dentist those functions which do not require the professional skill and judgment of the dentist and are in compliance with laws of states which have provisions for expanded functions, and be it further Resolved, that the dentists, and only the dentist, is responsible for the examination, making the diagnosis and formulating the plan of treatment, performing surgical or cutting procedures on hard or soft tissue, fitting and adjusting corrective and prosthodontic appliances, prescribing therapeutic agents and making impressions for other than study casts, and be it further Resolved, that final decisions related to dental practice and utilization of dental auxiliaries rest with the state society and the state board of dentistry, and be it further Resolved, that the AGD recognize the necessity of effectively utilizing dental auxiliaries to maximize the efficient use of the dentist's time and skills." Dental Practice Amalgam, position statement supporting 2002:24-H-7 “Resolved, that based on current scientific evidence, including the Food and Drug Administration’s February 2002 Consumer Update on Dental Amalgam, the Academy of General Dentistry maintains that amalgam is safe and effective as a dental restorative material.” Analyzed health care data Methodology and source of funding must be disclosed if used for Benefit determination 2000:24-H-7 “Resolved, that if information gathered from analyzed healthcare data is used for either benefit determination or dentist preferential selection, then the methodology and source of funding involved in the analysis must be publicly disclosed and verified by a process that ensures the quality, integrity, and validity of the analysis methodology.” Uses for, procedures must be publicly disclosed 2000:23-H-7 “Resolved, that the Academy of General Dentistry supports the concept that if health care data is analyzed, it should only be used to advance scientific knowledge or improve the oral health of the patient, while still allowing for professional judgments by practitioners, and be it further 60 For AGD Constituent Use Only Resolved, that the procedures involved in the analysis must be publicly disclosed and reviewed by the affected communities of interest in order to ensure the quality, integrity, and validity of the analysis methodology.” ANSI MD 156, AGD representative on 97:25-H-8 “Resolved, that the Academy of General Dentistry recognizes the problem of providing the general practitioner with meaningful information upon which to base purchasing decisions, and be it further Resolved, that the following strategies be implemented in order to accomplish this purpose: 1. Maintain an AGD representative on ANSI MD 156. 2. Recommend members to participate on ANSI subcommittees through the Dental Care Council Chairperson. 3. Relay to the ADA AGD's concerns with regard to having the practicing dentist more informed in order to make proper purchasing decisions. 4. Obtain feedback from our members on materials with which they’ve experienced problems.” Appropriate charges made for administrative work 75:28-H-10 "Resolved, that the AGD recognize that it is ethical and proper for appropriate charges to be made when a dentist completes a claim form, a narrative report or other paperwork requiring secretarial, clerical, and professional time as long as the fee is identified." Benefit coverage for dental surgery performed in office 79:35-H-6 "Resolved, that AGD support the inclusion of clauses in hospitalization and surgical benefits contracts that provide for coverage for dental surgery in the office setting if such surgery would normally be covered were the patient hospitalized for the procedure." Biophosphonate therapy 2007:27R-H-8 “Resolved, that the AGD communicate the potential serious oral sequelae of bisphosphonate therapy, including osteonecrosis, to the medical and dental communities, and to inform patients of such risk and encourage patients to seek dental care prior to initiating bisphosphonate therapy." Bleaching trays, license should be required for fabrication of 61 For AGD Constituent Use Only 2001:27-H-8 “Resolved, that the Academy of General Dentistry believes that supervising or providing materials or methodology for consumers to make intraoral impressions constitutes the practice of dentistry, which requires an appropriate license in the state or province where the individual is being treated, and be it further Resolved, that directing a dental laboratory to fabricate intraoral appliances and devices (including bleaching trays) constitutes the practice of dentistry, which requires an appropriate license in the state or province where the individual is being treated, and be it further Resolved, that in order to protect the health of the public, the Academy of General Dentistry believes that the fabrication of intraoral appliances and devices (including bleaching trays) by dental laboratories requires a proper prescription by a dentist licensed in the state or province where the individual is being treated.” Botulinum toxin and cosmetic dermal filler procedures, education in and performance of 2010:308R-H-7 “Resolved, that the AGD supports general dentists receiving education on, and the performance of botulinum toxin and cosmetic dermal filler procedures.” Child’s first visit to dentist, position on 98:24-H-7 “Resolved, that the Academy of General Dentistry officially endorse the position that a child’s first visit to the dentist should occur within six months of the eruption of the first tooth.” Claims, prompt payment of 93:22-H-7 "Resolved, that the Academy of General Dentistry ascribes to the American Dental Association's policy on the prompt payment of dental claims, which reads: 'Resolved, that the appropriate agencies of the American Dental Association, and its constituent dental societies, be urged to seek legislation which would require all public and private third-party payers to reimburse dental claims within (15) business days from receipt of the claim by the third-party payer or be penalized for failure to do so.'" Closed panel, opposed to *72:9-H-10 RESCINDED HOD 7/99 Code of procedures, endorsed by AGD 74:12-H-11 "Resolved, that the AGD endorse the principle of one code of procedures for dentistry, and be it further 62 For AGD Constituent Use Only Resolved, that whenever the ADA Council on Dental Benefit Programs or one of its sub-committees considers revisions in the ADA code the Academy of General Dentistry be permitted direct input into such revisions by having representation at those meetings, and be it further Resolved, that the AGD urge the American Dental Association to take steps to assure that the approved code is used throughout the purview of the Academy of General Dentistry." Consultant, ground rules for claims denial 93:27-H-7 "Resolved, that when a third-party dental consultant applies an alternative benefit provision to the treatment plan submitted by the provider dentist, or when a third-party dental consultant denies benefits for reasons other than contract exclusions, the dental consultant must sign the report and provide his/her telephone number, and be it further Resolved, that the AGD promote this concept to the American Dental Association, the Canadian Dental Association and third-party payment groups." Co-payment and overbilling, waiver of 93:23-H-7 "Resolved, that the Academy of General Dentistry adopt the American Dental Association's policies regarding waiver of copayment and overbilling, which read: 'Resolved, that constituent dental societies be urged to pursue enactment of legislation that: 1) 2) prohibits systematic non-disclosure of waiver of patient co-payment/overbilling by a dentist and prohibits bad faith insurance practices by third party payers, consistent with Association policy, and be it further Resolved, that third-party payers be urged to support this legislative objective.'" Corporate Guidelines and Mandates 2009:319S-H-7 “Resolved, that the AGD is opposed, as unduly burdensome to general dentistry and the patients it serves, to all corporate mandates that require specified quantities of utilization of the corporation’s products in patient’s dental treatment, without any qualitative assessment of each dentist’s proficiency with the products and without substantial clinical evidence of patient harm as a result of utilization in less than the specified quantities, as prerequisites for continued access to the use of the corporation’s product. Date of manufacture of dental equipment and devices 63 For AGD Constituent Use Only 81:26-H-7 "Resolved, that AGD encourage that ADA specifications for dental materials and devices include an expiration date where applicable, and when not applicable a date of manufacture or packaging, and be it further Resolved, that the type of date utilized be clearly indicated and separate from a lot or serial number." Dental health education for the public 81:33-H-7 "Resolved, that AGD support the concept of having public funds used to support dental health education for the public." 2006:23R-H-7 “Resolved, that AGD seeks to educate the public about the potential financial & health risks, due to lack of legal and contractual insurance recourse when medical & dental care is sought outside of the United States and Canada.” Dental hygienists, authority of State Boards of Dental Examiners 92:34-H-7 "Resolved, that because of the nature of dentistry and the manner in which it is delivered to the public, it is the policy of the Academy of General Dentistry that dental hygiene should remain under the authority of the various state boards of dental examiners and that dental hygiene education should remain under the purview of and be accredited by the Joint Commission on Dental Accreditation." Dental Implants 2008:317-H-7 “Resolved, that the AGD policy shall be that dental implants are an accepted modality of treatment.” 2009:301S-H-7 “Resolved, that the AGD support legislation requiring insurance carriers to cover reimbursement for surgical implant placement and restoration.” 2009:306-H-7 2009:307-H-7 “Resolved, that, when one or more dentists are involved in dental implant therapy, there should be mutual agreement of the restorative objectives by all parties, including the patient, before any invasive therapy is undertaken.” "Resolved, that the AGD adopt the Educational Objectives for the Provision of Dental Implant Therapy.” Dental insurance plan to include all facets of dentistry 82:32-H-7 "Resolved, that the AGD recognize that an optimum dental benefits plan includes all facets of dentistry." 64 For AGD Constituent Use Only Dental materials, products, and/or medications, use in oral healthcare 2010:306RS1-H-7 “Resolved, that HOD Policy 99:36-H-7 and HOD Policy 2002:25-H-7 be rescinded and be it further, Resolved, that the AGD take appropriate action when necessary to ensure that safe and effective dental materials, products, and/or medications remain approved for use in oral healthcare.” Dental research, public funding for 81:35-H-7 "Resolved, that the AGD support the concept of using public funds if available for dental research." Dentistry's position on a National Health Program 80:25-H-7 "Resolved, that AGD's Guidelines for Dentistry's Position on a National Health Program and other relevant AGD and ADA policy be reviewed in relation to any future legislation mandating dental benefits." Dentist's right to collect a larger fee from patient 77:14-H-6 "Resolved, that the AGD is opposed to any administrative procedure by a third party payment mechanism which interferes with the dentist's right to collect from a patient a fee greater than that allowed by the carrier's benefit structure except when a dentist has agreed to become a participant in a benefits program that utilizes a usual, customary, and reasonable method of reimbursement as payment in full.” Diagnosis and supervision needed for dental treatment 2003:16-H-7 “Resolved, that dental treatment, including the placement of dental sealants and fluoride varnishes, is most effectively and successfully accomplished following a proper diagnosis by, and under the supervision of a licensed dentist in compliance with the regulations of the state or province, and in a dental office setting that ensures optimal treatment outcomes.” Diagnostic tests, dentists’ right to prescribe and perform 97:26-H-8 “Resolved, that the Academy of General Dentistry recognizes that dentists have the right to prescribe and perform any diagnostic tests deemed necessary providing that: 1. The test is required for the oral diagnosis of or treatment planning for the patient, or the management of a percutaneous injury in a clinical setting. 2. The patient has given informed consent. 65 For AGD Constituent Use Only 3. The test is accompanied, where appropriate, by adequate pre- and postcounseling. 4. There is provision for appropriate referral to a physician responsible for the comprehensive medical care of the patient.” Environmental “best management” practices 2003:12-H-7 “Resolved, that the AGD urge dentists to employ environmental “best management” practices as supported and/or promoted by the American Dental Association and in Canada by the Canadian Dental Association, and be it further Resolved, that AGD constituents be encouraged to work with their counterpart dental societies to adopt and promote environmental best management practices.” Evidence-based dentistry Definition of 2000:22A-H-7 “Resolved, that the Academy of General Dentistry believes that evidencebased dentistry is an approach to treatment planning and subsequent dental therapy that requires the judicious melding of systematic assessments of scientific evidence relating to the patient’s medical condition and history, the dentist’s clinical experience, training, and judgment, and the patient’s treatment needs and preferences.” Use of 2000:22B-H-7 “Resolved, that evidence-based dentistry be utilized to promote the delivery of the most effective care for the patient and not for the determination of dental benefits.” Fees, adjustment of 93:25-H-7 "Resolved, that the Academy of General Dentistry recognizes that dentists may, upon occasion, adjust fees to classes of individuals, such as relatives, clergy, staff, senior citizens, the indigent, and be it further Resolved, that any occasional fee adjustments should not be reflected in determination of UCRs by third parties, and be it further Resolved, that the Academy of General Dentistry recommends that this be properly recorded in the dentist's records." Fees; i.e., usual, reasonable, customary: definition of 93:24-H-7 "Resolved, that the Academy of General Dentistry adopt the American Dental Association's definitions of and policies regarding 'usual, customary 66 For AGD Constituent Use Only and reasonable fees,' which read: 'Usual fee' is the fee which an individual dentist most frequently charges for a specific dental procedure. 'Reasonable fee' is the fee charged by a dentist for a specific dental procedure which has been modified by the nature and severity of the condition being treated and by any medical or dental complications or unusual circumstances, and therefore may differ from the dentist's "usual" fee or the benefit administrator's "customary" fee. 'Customary fee' is the fee level determined by the administrator of a dental benefit plan from actual submitted fees for a specific dental procedure to establish the maximum benefit payable under a given plan for the specific procedure." First Dental Visit Timing and Establishment of the Dental Home (AAP Policy Proposal) 2002:22-H-7 Resolved, that the Academy of General Dentistry endorses the American Academy of Pediatrics Policy Proposal from the AAP Section on Pediatric Dentistry entitled “First Dental Visit Timing and Establishment of the Dental Home”, and be it further Resolved, that the Academy of General Dentistry communicate this endorsement to the American Academy of Pediatrics.” Flexible Spending 2008:308-H-7 “Resolved, that the AGD support the expansion of Flexible Spending Account (FSA) reimbursable health items to include oral health items.” Fluoridated public water supplies, public funding for 81:32-H-7 "Resolved, that the AGD support the use of public funds to assist local and state governments in seeing that their public water supplies are adequately fluoridated." Fluoride in water supplies and toothpaste, position statement 2002:21-H-7 “Resolved, that based on the Center for Disease Control’s Recommendations for Using Fluoride, the AGD adopt the following position statement: When used appropriately, fluoride is safe and effective in preventing and controlling dental caries. Regular use throughout life will help protect teeth against decay. All water supplies, including bottled water, should have appropriate fluoride levels. All fluoridated items, including toothpaste, should be used as recommended by your dentist.” Freedom of choice provider 67 For AGD Constituent Use Only 94:30-H-7 "Resolved, that the Academy of General Dentistry actively support "freedom of choice" legislation permitting patients to freely choose their dentist while continuing to utilize their full dental benefits, and be it further Resolved, that the Academy of General Dentistry actively support "any willing provider" legislation to allow dentists to enroll at any time and to freely participate in dental third-party programs." Health care reform 2009:316-H-7 “Resolved, that the Academy of General Dentistry participate in any legislative discussions regarding health care reform.” Health care reform criteria 93:28-H-7 "Resolved, that it is the policy of the Academy of General Dentistry that if dentistry is to be included in any government health care program reform, it must: 1) 2) 3) 4) Be adequately funded to provide broad access; Permit freedom of choice of dentists; Be based on fee-for-service; and Assure high quality dental care. and be it further Resolved, in any case where dentistry is included in health care reform, the AGD support the following six recommendations set forth by the American Dental Association: 1. Maintain the advantages of the current dental care and dental benefits system, which would not require inclusion of dental benefits for population groups currently receiving regular dental care, and which would not require public sector participation and subsequent cost transfer. The Association strongly opposes any change in the tax deductibility of current dental benefit coverage. 2. Continue existing policy support for a separate, restructured program of publicly funded dental benefits for indigent persons. Priority consideration should be given to programs for children. The Association urges that these programs be administered in the private sector wherever possible. 3. For population groups currently not receiving regular dental care the Association supports the opportunity for a) small employers purchase dental plans in the private sector, b) development of cooperative dental benefit purchasing alliances administered in the private sector. 68 For AGD Constituent Use Only 4. The Association recommends that preventive services and educational programs for children be included in any health system reform proposal. Preventive services may include but are not necessarily limited to, fluoridation of community water supplies, oral prophylaxis and application of topical fluorides and sealants; dietary fluoride supplements; restoration of carious teeth; maintenance of space resulting from the early loss of primary teeth and patient education. 5. The Association recommends that in the event that a more comprehensive program is enacted, preventive, diagnostic, emergency services and basic restorative and periodontal care be included for children and the elderly. 6. The Association believes that if the Medicare program is expanded to include coverage for additional dental health care services, we would endorse the inclusion of a defined dental benefit plan for the elderly population. These services would be expressly focused on those elderly who are in long-term residential care or home-bound. Delivery of these services should not be compromised by discrimination by category of provider (physician or dentist)." Issue priorities for government funding *79:27-H-6 RESCINDED *81:30-H-7 RESCINDED 94:20-H-7 "Resolved that the following policies be rescinded: 77:20-H-6 Superseded by 1992 House Resolution 79:27-H-6 Outdated 81:30-H-7 Outdated 75:37-H-10 Outdated 91:49-H-7 Superseded by 1992 House Action on reform Licensing Criteria for eligibility 2002:28-H-7 “Resolved, that the Academy of General Dentistry believes that to be eligible to apply for an initial license to practice dentistry in the United States or Canada, the candidate must have: 1.) Graduated from a dental college with training that is equivalent or 69 For AGD Constituent Use Only 2.) 3.) higher than that provided by a dental college approved by the American Dental Association’s Commission on Dental Accreditation or the Canadian Commission on Dental Accreditation, Passed Part I and Part II of the National Board Exam (or the National Dental Examining Board Exam in Canada), and Passed a state or provincial licensing examination, or its equivalent, as determined by the state or provincial board of dentistry, and any additional requirements.” Uniform standards for 2002:27-H-7 “Resolved, that the AGD actively support a uniform standard for licensing dentists in all U.S. states and Canadian Provinces, and be it further Resolved, that access to oral health care for underserved populations should be addressed by maintaining uniformly enforced licensing standards that would prevent an unequal and unacceptable two-tier level of care, and be it further Resolved that the AGD believes that access to care in underserved areas should be solved by instituting adequate financial incentives or loan forgiveness to properly licensed dentists.” Voluntary/Temporary Licensing 2009:311-H-7 “Resolved, that the AGD approve the policy Supporting Issuance of Volunteer/Temporary Licenses for Dentists Licensed in Different States” “Resolved, that the AGD supports the issuance of a temporary license to do volunteer dentistry by dental licensing boards to dentists who are licensed in another state or province when such dentists are seeking such license in order to provide volunteer or charity care.” Manpower problems *79:34-H-6 RESCINDED HOD 7/99 Medically compromised dental patients Disclosure of relevant information 88:54-H-7 "Resolved, that all legislation and regulations to protect confidentiality of information on medically compromised or handicapped patients provide for disclosure of relevant information to members of the individual's direct care-giving team." Policy statement on treatment of 88:48-H-7 "Resolved, that the AGD adopt the following policy: 70 For AGD Constituent Use Only AGD POLICY STATEMENT ON TREATMENT OF MEDICALLY COMPROMISED DENTAL PATIENTS With the aging of the population and the spread of infectious diseases, dentists will encounter growing numbers of medically compromised patients, including those with infectious diseases. The general dentist, as primary dental care provider, plays the key role in providing and coordinating dental care for such patients. In this role dentists have responsibilities to all patients, staff and other parties which they are ethically bound to fulfill. Responsibilities to the Medically Compromised Patient o To treat the patient with kindness and compassion, regardless of the nature of the patient's condition. o To be sufficiently educated to evaluate the dental health of a medically compromised patient and to consult with physicians, when necessary, regarding the patient's medical status. o To provide appropriate treatment within the dentist's realm of competence. Responsibilities to Dental Staff o To ensure that staff are trained in emergency care, the management of special health conditions and the management of medically compromised patients. o To advise staff of the health status of each patient so they may employ appropriate procedures and avoid procedures that may place themselves or the patient at unnecessary risk. o To ensure that all staff members are properly educated so they understand that infection control measures, including barrier techniques are in place and practiced routinely to protect them against disease. With this understanding they can properly render compassionate care to a medically compromised patient. Responsibility to Other Parties o Dentists must observe state and/or federal laws and regulations that require providers to protect the confidentiality of the patient. Ethical Considerations for Treating HIV Positive Patients The AGD believes that dentists are obligated to observe the American Dental Association's Principles of Ethics and Code of Professional Conduct in the treatment of all patients including those who are medically compromised, of which HIV positive patients are a part." 71 For AGD Constituent Use Only Medically indigent, support programs for 77:18-H-6 "Resolved, that every effort be made to have indigent dental care programs structured so that they take into consideration the current cost basis involved in providing the dental services." 81:31-H-7 "Resolved, that AGD support viable programs to provide dental care to the needy elderly and medically indigent." 81:34-H-7 "Resolved, that the AGD support the concept of using public funds if available to provide dental care for the medically indigent." Medicare, amendment to reimburse dentists for rendering same service as a physician 79:28-H-6 "Resolved, that the AGD support the concept of amending Medicare so that a dentist shall be reimbursed for a dental service rendered under this program if a physician would have been reimbursed for rendering the same service." Nutrition and oral health 2004:14-H-7 “Resolved, that the Academy of General Dentistry encourages dentists to maintain ongoing knowledge of nutritional recommendations such as in the Dietary Guidelines for Americans published by the U.S. Department of Agriculture and the U.S. Department of Health and Human Services and their Canadian counterparts, as they relate to general and oral health and disease, and be it further Resolved, that the Academy of General Dentistry encourage dentists to effectively educate and counsel their patients about proper nutrition and oral health, including eating a well balanced diet and limiting the number of highly cariogenic between-meal snacks, and be it further, Resolved, that the Academy of General Dentistry encourage constituent academies to work with school officials to ensure that school food services, including vending services and school stores, provide nutritious food selections, and be it further Resolved, that the Academy of General Dentistry opposes targeting children in the promotion and advertisement of foods low in nutritional value and highly cariogenic foods and beverages and be it further Resolved, that the Academy of General Dentistry encourages continued federal support for programs that provide nutrition services and education for infants, children, pregnant women and the elderly, and be it further, 72 For AGD Constituent Use Only Resolved, that the Academy of General Dentistry encourages the appropriate government agencies to prevent the distribution of non-nutritious and highly cariogenic foods and beverages under federal nutrition service programs.” Oral Conscious Sedation, position statement 2005:2R-H-7 “Resolved, that the AGD position on Oral Conscious Sedation is: 1. The Academy of General dentistry believes that the general dentist must have access to appropriate training in the area of anxiolysis and oral conscious sedation. The AGD further believes that continuing education opportunities must continue to be developed to make these courses available to the general practitioner. 2. “Anxiolysis” means removing, eliminating or decreasing anxiety. This may be accomplished by the use of medication that is administered in an amount consistent with the manufacturer’s current recommended dosage and/or judgment on the part of the clinician with or without nitrous oxide and oxygen. When the intent is anxiolysis only, the definition of enteral and/or combination inhalation-enteral conscious sedation (combined conscious sedation) does not apply. 3. The Academy of General Dentistry supports the rights of the general dentist to use professional judgment in deciding the appropriate dose for each patient situation, respecting safe dosing parameters. 4. The Academy of General Dentistry believes that each constituent should be in close contact with their licensing boards to communicate the AGD’s position on this issue.” Parameters of care, ADA 91:46-H-7 "Resolved, that the Board be directed to take a firm position that protects and accurately represents the interests of practicing general dentists on the development of parameters of care prior to consideration by the ADA House of Delegates after weighing all available evidence on the issue, including input from the Chairman of the AGD Dental Practice Council." Parameters of care, criteria for 93:26-H-7 "Resolved, that any parameter of care established for the entire dental profession should be: 1. Condition-based; 2. Equally applicable to all dental care providers; 3. Universally accepted with the dental profession; and 73 For AGD Constituent Use Only 4. Developed by the American Dental Association with appropriate representation by the affected communities of interest, including the AGD as the representative of general practitioners; and be it further Resolved, that the AGD's Dental Practice Council shall continue to monitor the status of parameters and attempt to achieve AGD representation in the development of parameters, and be it further Resolved, that the AGD reserves the right to develop its own parameters should the need arise." 94:32-H-7 "Resolved, that any parameter of care established for the entire dental profession should be: 1. Condition-based; 2. Equally applicable to all dental care providers; 3. Universally accepted within the dental profession; and 4. Developed by the American Dental Association with appropriate representation by the affected communities of interest, including the AGD as the representative of general practitioners; and be it further Resolved, that the AGD's Dental Practice Council shall continue to monitor the status of parameters and attempt to achieve AGD representation in the development of parameters, and be it further Resolved, that the AGD reserves the right to develop its own parameters or oppose the development of parameters should the need arise." Preferred Provider Organizations 84:26-H-7 "Resolved, that the Academy of General Dentistry use whatever means are available to ensure that the following provisions are included in and made a part of any state and/or federal law mandating and/or regulating preferred provider organizations: A. Patients' freedom of choice of provider must be guaranteed. B. Preferred provider policies or contracts and preferred provider subscription contracts shall provide the same benefits level to the patient whether rendered by non-preferred providers or preferred providers. C. No dentist willing to meet the terms and conditions offered by a PPO shall be excluded. D. All types of licensed health care providers whose services are required shall have the same opportunity to qualify for payment as a preferred provider under any such policies. 74 For AGD Constituent Use Only E. The terms and conditions of any PPO policies or contracts shall not discriminate against or among health care providers. F. A preferred provider subscription contract should be defined as a contract which specifies how services are to be covered by the plan when rendered by non-participating providers and by preferred providers. G. Preferred provider policies or contracts should be defined as insurance policies or contracts which specify how services are to be covered by the plan when rendered by preferred and non-preferred providers. H. When preferred provider organizations are promoted to the public, they cannot do so with any implications of superiority, and all promotional materials used by PPOs must state if a preferred provider is a reduced fee contract. I. The PPO shall make provision for a periodic adjustment in level of reimbursement based on the Consumer Price Index or some other equitable basis. And be it further Resolved, that the Academy of General Dentistry encourage its Constituent Academies to work toward building these safeguards into any state and/or federal law mandating and/or regulating preferred provider organizations. And be it further Resolved, that the Academy of General Dentistry transmit this position to the American Dental Association's Dental Practice Council Programs." Prepayment plans Bill payer system 78:24-H-6 "Resolved, that the AGD recognize the 'bill payer system' (direct reimbursement) as one of the acceptable forms of dental prepayment." Exclude certain contract language 77:12-H-6 "Resolved, that in the interest of providing the best possible level of dental care for the patient, the Academy of General Dentistry is opposed to the inclusion of 'least expensive but adequate treatment', 'alternate mode of treatment', or similar contract language, in prepayment dental plans, and be it further Resolved, that such language be eliminated from prepayment contracts wherever possible, and be it further 75 For AGD Constituent Use Only Resolved, that this type of language in existing dental contracts be implemented in such a manner so as not to impugn the integrity of the attending dentist or intrude upon the patient-dentist relationship by either informing or implying that an alternate mode of treatment is appropriate, or influence the patient in any way in his choice of the attending dentist's treatment, and be it further Resolved, that the 1976 House of Delegates' substitute resolution for #35 be rescinded." Include all phases of preventive dental services 81:29-H-7 "Resolved, that the AGD recognize the necessity of having all phases of preventive dental services in the dentist's office included in dental prepayment plans, and be it further Resolved, that AGD request the appropriate agencies of the American Dental Association to consider the development of a position statement that would serve to accomplish this purpose." Structuring of dental prepayment programs 77:17-H-6 "Resolved, that third party mechanisms, including government programs, take these differences into consideration in structuring dental prepayment programs, and be it further Resolved, that dental prepayment programs for the non-indigent have a provision whereby the patient will pay the differences between the fee authorized under the program and the normal fee charged." Public information available to public of dental office safety 92:30-H-7 "Resolved, that the Academy of General Dentistry believes that any advertisement of the HIV status of the dentist or any member of the dental team is misleading to the dental consumer and be it further Resolved, that all members and dental personnel are encouraged to work to educate the public and all patients on the safety of dental procedures and the precautions taken by dental professionals to safeguard patients' health in the dental office." Resource-Based Relative Value Scale 89:53-H-7 "Resolved, that the Academy of General Dentistry opposes use of the Resource-Based Relative Value Scale as a method of determining payment for services provided by dentists." 76 For AGD Constituent Use Only Rights of employers to provide health care benefits 80:24-H-7 "Resolved, that AGD agrees in principle with the traditional rights of all employers to provide health care benefits for their employees, and be it further Resolved, that AGD continue its dialogue with the ADA to clarify any proposal to provide dental benefits to federal employees." School curricula – oral health education 2002:23-H-7 “Resolved, that the Academy of General Dentistry advocates incorporation of oral health education into primary and secondary school curricula with measurable outcomes, as a proven and cost effective disease prevention and universal health promotion program.” Soft drink consumption/pouring rights contracts 2004:13-H-7 “Resolved, that the Academy of General Dentistry, through its appropriate agencies, continue to review the supporting data concerning the oral health effects of the increasing consumption of beverages containing sugars, carbonation or acidic components. These products are commonly referred to as “soft drinks,” including but not limited to juice drinks, sports drinks and soda pop, and be it further Resolved, that the Academy of General Dentistry encourages its constituents to work with education officials, pediatric and family practice physicians, dietetic professionals, parent groups, and other interested parties, to increase the awareness of the importance of maintaining healthy vending choices in schools, and to encourage the promotion of fluoridated water and beverages of high nutritional value, and be it further Resolved, that the Academy of General Dentistry opposes contractual arrangements, including pouring rights contracts, that influence the consumption patterns that promote increased access to ‘soft drinks’ for children.” Supervision, definitions of for dental hygienists and other dental auxiliaries 85:27-H-7 "Resolved, that the Academy of General Dentistry believes that a dental hygienist or other dental auxiliary, in accordance with their training and education, and state law, shall, under a dentist's supervision, perform those aspects of treatment delegated by that dentist; and be it further Resolved, that the setting in which a dental hygienist or other dental auxiliary may perform legally designated functions shall be a treatment facility under the jurisdiction and supervision of a licensed dentist; and be if further Resolved, that the AGD shall use the following definitions of 'supervision': 77 For AGD Constituent Use Only General Supervision means that the dentist has authorized the procedures and they are being carried out in accordance with his/her diagnosis and treatment plan. Indirect Supervision means that the dentist is in the dental office, authorizes the procedure and remains in the dental office while the procedures are being performed by the auxiliary. Direct Supervision means that the dentist is in the dental office, personally diagnoses the condition to be treated, personally authorizes the procedure and before dismissal of the patient, evaluates the performance of the dental auxiliary. Personal Supervision means that the dentist is personally operating on a patient and authorizes the auxiliary to aid his/her treatment by concurrently performing a supportive procedure." 2008:321-H-7 “Resolved, that the AGD define and incorporate into existing policies the definition of dental auxiliaries to include midlevel practitioners and all other individuals who are not licensed dentists, but otherwise provide oral health care.” Surgeon General's Report on Oral Health Implementation plan 2001:26-H-8 “Resolved, that it is the role of the Academy of General Dentistry to implement the Surgeon General’s Report on Oral Health by: 1. 2. Expanding the demand for and availability of dental continuing education opportunities that: a. Address the management of the oral health needs of at-risk toddlers, children, special needs, and geriatric patients. b. Expand the knowledge of practicing dentists in the areas of oral medicine and the relationships between oral health and general health. Working with other health care organizations to expand and elevate the knowledge of health care professionals, policy-makers, and the public (with an emphasis towards underserved communities) about: a. The relationships between oral health and general health. b. Oral disease prevention measures including home care, nutrition, fluoride, sealants, and tobacco cessation. 78 For AGD Constituent Use Only c. 3. Promoting oral health in school curricula. Advocate the development and implementation of appropriate proactive measures that will improve access to dental care (such as student loan forgiveness, tax credits and/or incentives to induce recent dental school graduates to practice in underserved areas).” Third party mechanisms ADA's role in problems with 81:27-H-7 "Resolved, that the AGD recognize the American Dental Association's appropriate role in communicating with third party payment mechanisms for the purpose of upholding prepayment standards which have been agreed upon by the profession, and be it further Resolved, that all complaints involving third party payment mechanisms taking more than 30 days to reimburse patients or dentists for dental services rendered be referred to the ADA so that appropriate dialogue may be instituted with the third party on behalf of the public and the dental profession." Claim contested by dental consultant of 75:30-H-10 "Resolved, that should a patient's claim be contested by the third party's dental consultant, patient, or the patient's dentist, it shall be submitted to the local level of organized dentistry's peer review system and the third party, the patient, and the dentist should agree that the action of the peer review system is binding." Considerations in deliberating dental health insurance programs 74:8-H-11 "Resolved, that the Academy of General Dentistry take into consideration the needs of the public, the various third party pre-payment mechanisms, and the entire dental profession in deliberating on dental health benefits programs which might be of concern to the general dentists which compose its organization." Consultant of, should make no representation to patient regarding dentist's service or fee 75:29-H-10 "Resolved, that when a patient's claim is considered for modification, and/or review, the third party dental consultant should contact the patient's dentist to discuss the matter fully rather than making any representation to the patient with respect to the dentist's services or fees." Diagnostic imaging 94:15-H-7 "Resolved, that the Academy of General Dentistry supports third-party 79 For AGD Constituent Use Only reimbursement for all forms of diagnostic imaging determined to be medically necessary by the treating dentist and supported by appropriate clinical criteria." Differentials in levels of reimbursement in 77:13-H-6 "Resolved, that the Academy of General Dentistry is opposed to differentials in levels of reimbursement in third party programs based on whether or not a practicing dentist is a 'participating' or 'non-participating' dentist in such a program, and be it further Resolved, that this resolution be communicated to the ADA, Delta Dental Plans, and all of the participating Delta Dental Plans in every state in the United States." 86:34-H-7 "Resolved, that the AGD is unequivocally opposed to any type of separate fee schedules for reimbursement to general practitioners and specialists for the same or similar services; and be it further Resolved, that AGD policy #76:53-H-11 be rescinded." (Second and Third Clauses rescinded HOD 2007:301-H-7, see rescinded policies) Fee Determination 2009:317RS-H-7 “Resolved, that third party payers should not determine fees for procedures not covered and/or not reimbursed in their policies. And be it further, Resolved, that the appropriate AGD agencies be directed to help AGD constituents develop legislation that will prevent third party payers from setting fees for non-covered and/or non-reimbursed procedures.” Fee schedules based on utilization reviews considered arbitrary 2000:25-H-7 “Resolved, that the Academy of General Dentistry believes that any fee schedule by third party dental benefit administrators or other entities that separates dentists into different payment levels as determined by statistically based ‘utilization reviews’ is arbitrary, discriminatory, and not consistent with appropriate patient care.” Guidelines for handling members’ problems with 75:33-H-10 "Resolved, that the AGD adopt the following guidelines for handling communications from members on their problems with third party programs: a. All complaints must be placed in writing and be sufficiently documented. 80 For AGD Constituent Use Only b. The executive director, in consultation with the Dental Care Council chairman, shall be charged with the responsibility of corresponding directly with those carriers that are acting in opposition to policy previously established by the AGD. c. The AGD should seek the help of the American Dental Association on those complaints involving a violation in ADA policy." Not to interfere with dentist's diagnosis and treatment 75:32-H-10 "Resolved, that the AGD recognize a third party payment mechanism's responsibility to determine its liability and extent of dental benefits but is unalterably opposed to any administrative procedure that interferes with the attending dentist's diagnosis and treatment plan." 86:33-H-7 "Resolved, that alternative payment systems for all dental care delivery should not infringe upon the right and responsibility of the licensed practicing dentist to diagnose and treat patients according to the proper standard of care." Overpayment recovery practices 2003:13-H-7 “Resolved, that the Academy of General Dentistry seek and support efforts opposing third party overpayment recovery practices, except as contractually obligated, when the overpayment was the result of a mistake made by the insurer and accepted by the dentist in good faith without prior or reasonable knowledge of the error, and be it further Resolved, that the Academy of General Dentistry seek and support efforts to prevent third party payers from withholding fully assigned benefits to a dentist when an incorrect payment has been made to the dentist on behalf of the subscriber with the same third party payer.” Participation should not be contingent upon participation in government regulated programs 97:30-H-8 “Resolved, that retention of a license to practice dentistry and participation in third party plans should not be contingent upon participation in government regulated programs.” Reduction/denial of dental benefits must be signed by licensed dentist 2000:26-H-7 “Resolved, that the Academy of General Dentistry believes that any third party reduction or denial of dental benefits on the basis of ‘not medically necessary or appropriate’ must be made on an individual basis and signed by a dentist licensed in the state or province in which the procedures are being performed, and be it further Resolved, that the Academy of General Dentistry believes that any third party reduction of dental benefits on the basis of ‘least expensive alternative 81 For AGD Constituent Use Only treatment’ be made on an individual basis and signed by a dentist licensed in the state or province in which the procedures are being performed, and be it further Resolved, that the Academy of General Dentistry believes that any review of clinical records for the purpose of reducing or denying dental benefits must be made on an individual basis and signed by a dentist licensed in the state or province in which the procedures are being performed.” Regulated by law or state governmental agency 85:23-H-7 "Resolved, that all third-party payment mechanisms be regulated by law or through the appropriate state governmental agency to ensure fiscal responsibility and protection of the interests of the public." Tissue biopsy 2006:25-H-8 “Resolved, that it is the position of the AGD that the decision whether or not to biopsy oral tissues lies within the purview of the treating dentist.” TMD policy statement 86:29-H-7 "Resolved, that the Academy of General Dentistry support legislation and rules and regulations that would require third-party mechanisms selling dental benefits programs based on UCR in a state, to use data that is not more than six months old on the date of filing, and so state this date in published material to users and prospective users of these programs; and be it further Resolved, that the AGD communicate the problems being addressed by this resolution to the ADA's Council on Dental Benefit Programs to seek a viable solution; and be it further Resolved, that the AGD's Dental Practice Council assess solutions being offered by the ADA to see if further action by the AGD is needed." 89:55-H-7 "Resolved, that the Academy of General Dentistry's TMD Policy is: 1. The existence of TM orders is undeniable and these disorders can be treated by the general dentist. 2. There are a variety of viable diagnostic and treatment modalities for TM disorders, as there are in the treatment of physiological disorders, back problems, and many other medical maladies. 3. Like any disorder or disease, the indication for TMD treatment is a doctor/patient decision. The criteria for this decision is both subjective and objective. 4. It is not possible to list all the effective (and thus reimbursable) TMD procedures. It is the application of clinical judgment which determines the appropriate treatment modality. 82 For AGD Constituent Use Only and be it further Resolved, that the Academy of General Dentistry support the concept that comprehensive policies or certificates of health, medical, hospitalization, or accident and sickness insurance should provide reimbursement for the diagnosis and therapeutic treatment of temporomandibular dysfunction/myofascial pain dysfunction and associated diseases and dysfunctions and that benefit coverage be the same as that for treatment of any other joint in the body and be applicable if the treatment is administered or prescribed by a physician or a dentist, and be it further Resolved, that Resolution 88:53-H-7 be rescinded." TMJ Medical care contracts should not discriminate against dentists 88:52-H-7 "Resolved, that in cases where dentists provide their expertise in treatment of temporo-mandibular joint dysfunction and cranio-mandibular disorders, medical care contracts should not discriminate in benefit payments based on the professional degree of the provider." Medical care contracts should provide mandatory coverage for treatment of *88:53-H-7 RESCINDED Tooth numbering system 81:28-H-7 "Resolved, that the Academy of General Dentistry endorses the universal (1 to 32/a to t) tooth numbering system adopted by the ADA and encourage its immediate implementation through the American Dental Association and the American Dental Education Association and other segments of the dental profession." Untoward responses to products, materials, and medications 98:23-H-7 “Resolved, that the Academy of General Dentistry encourage its members to be aware of possible untoward responses to products, materials, and/or medications used in the dental office, and that the use of these products, materials and/or medications will be up to the discretion of the treating provider.” Workforce, adequacy of present dental workforce 2002:26-H-7 “Resolved, that the Academy of General Dentistry adopt the following statement relative to the adequacy of the dentist workforce in 2002: The dentist workforce in the United States is sufficient to meet the needs of the public demand for dental services. Geographic imbalances exist in 83 For AGD Constituent Use Only localized areas due to a variety of factors. Where these imbalances result in shortages, the affected regions must be examined and addressed individually for appropriate solutions. The development of a responsive, competent, diverse, and “elastic” workforce should address potential increases in demand for dental services.” Work force issues, position statement 2005:3-H-07 “Resolved, that the Academy of General Dentistry’s position in response to work force issues is: AGD believes that access to oral health care is an issue that needs to be addressed throughout the profession. AGD believes that general and pediatric dentists, working in concert with the dental team, are the gatekeepers of oral health. AGD believes that general dentists are uniquely qualified to help provide and maintain the optimal standard of care.” Dental Consultant Coalition to restore deduction for student loan interest 93:29-H-7 "Resolved, that the Academy of General Dentistry support the efforts of the Student Loan Interest Deduction Restoration Coalition to restore the deduction of interest paid on student loans." Must be a licensed dentist 75:27-H-10 "Resolved, that the AGD recognizes that a dental consultant must be a duly licensed dentist within said state." Dental Education Deduction of interest paid on student loans 2008:301S-H-7 “Resolved, that the Academy of General Dentistry support efforts to restore the full deduction of interest paid on student loans regardless of income.” Dental schools, support state funding for 80:22-H-7 "Resolved, that AGD recognizes the need for adequate funding to enable dental schools to provide a proper dental education, but at the same time, AGD encourages dental schools to seek state and/or private support in lieu of federal capitation funding." 84 For AGD Constituent Use Only 81:37-H-7 "Resolved, that AGD support the concept of using state funds to assist in maintaining and operating the physical facilities of existing dental schools." Formal academic process leading to a degree or certificate 81:41-H-7 "Resolved, that AGD endorse the concept of a formal academic process of structured, sequential continued or post-doctoral education, earned through universities or academically accredited teaching institutions over an extended amount of time, which lead to a degree or a certificate." Four-year curriculum, support of 78:27-H-6 "Resolved, that the AGD expresses its concern with the dilution and shortening of dental school programs for purpose such as the receiving of federal capitation grants, and be it further Resolved, that the AGD supports a minimum of a four-year approved curriculum to achieve a dental degree, and be it further Resolved, that the AGD send a letter to all of the existing dental schools expressing our support of those dental schools which have relinquished their three-year programs in favor of pursuing quality four-year dental education programs." Liaison consortium 98:31-H-7 “Resolved, that the Academy of General Dentistry convene a ‘Liaison Consortium’ to consist of two representatives from the Academy of General Dentistry (AGD), two representatives from the American Dental Education Association (ADEA), two representatives from the American Association of Hospital Dentists (AAHD), one representative each from the Federal Services Board, the American Board of General Dentistry, and the Veteran’s Administration Residency Programs to meet twice each year beginning in April of 1999, and be it further Resolved, that the mission of the consortium will be to coordinate the representation of predoctoral and postdoctoral general dentistry educators by identifying their needs, facilitating communication, and promoting resource sharing among the involved organizations.” Licensure 82:34-H-7 "Resolved, that in states where laws are already in effect which mandate involvement in continuing education as a condition of dental licensure and/or dental license renewal, AGD's constituent AGD in that state's jurisdiction work with the state board of dental examiners and other appropriate dental agencies to protect the interests of AGD members in that state as mechanisms for enforcement and administration of that requirement are developed and implemented, and be it further 85 For AGD Constituent Use Only Resolved, that Resolution #76-51, as passed by the 1976 House of Delegates, be rescinded." 96:46-H-7 "Resolved, that the Academy of General Dentistry encourage its constituent academies to work with state or provincial boards of dental examiners, state legislatures, or regulatory bodies in implementing the following provisions for mandatory continuing dental education when legislation or regulations are under consideration in their states or provinces: 1. acceptance of program providers approved by the AGD of General Dentistry, ADA Continuing Dental Education Recognition Program and the AGD's intrastate approval program; 2. the acceptability of self-instruction programming; 3. acceptance of the AGD member printout as one form of documentation of the requirement; 4. acceptance of courses relative to the access and delivery of dental care." Dental Laboratory Techniques 76:40-H-11 "Resolved, that the Academy of General Dentistry urge the American Dental Association to, in turn, influence the schools of dentistry to provide significant instruction in dental laboratory technology for dental students so that dental school graduates will have the ability to adequately supervise the laboratory technicians, and be it further Resolved, that the Academy of General Dentistry urge the American Dental Association to, in turn, influence the schools of dentistry to institute programs of instruction to train dental laboratory technicians at the college and vocational school level, and be it further Resolved, that, with passage of this resolution, Resolution 75-61 as passed by the 1975 House of Delegates, be rescinded." Dental Materials 79:30-H-6 "Resolved, that the AGD recognizes the need to give the American Dental Association's Council on Dental Materials and Devices appropriate input from general dentists, and be it further Resolved, that the AGD recognizes the opportunity given to its president in the Bylaws to appoint an appropriate representative when it is appropriate for him to do so, and be it further Resolved, that the AGD's representative to the American National Standards Committee MD156 for Dental Materials and Devices be named as a consultant to the AGD's Dental Practice Council, if he is not already a member, and be it further 86 For AGD Constituent Use Only Resolved, that all problems concerning dental materials and devices be considered under the purview of the AGD Dental Practice Council." 79:31-H-6 "Resolved, that attendance at MD 156 Committee meetings by a representative of the Academy of General Dentistry be included in the Dental Practice Council's budget, on an annual basis." Purchasing decisions 82:31-H-7 "Resolved, that the Academy of General Dentistry recognizes the problem of providing the general practitioner with meaningful information upon which to base purchasing decisions, and be it further Resolved, that the following strategies be implemented in order to accomplish this purpose: 1. Maintain an AGD representative on ANSI MD 156. 2. Recommend through the Dental Care Council chairman members to participate on ANSI Subcommittees. 3. Relay to the ADA AGD's concerns with regard to having the practicing dentist more informed in order to make proper purchasing decisions. 4. Identify which products should be evaluated. 5. Relay ANSI information to the AGD Foundation Product Comparison Advisory Board. 6. Start Product Comparison Program through AGD Foundation. 7. Publish results of product comparison program in our Journal. 8. Obtain feedback from our membership on which products should be evaluated. 9. Appoint subcommittee of Dental Care Council to facilitate dental material and device deliberations for the Council." Dental Practices Open elections and nominations for officers 78:23-H-6 "Resolved, that all dental service corporations be requested to have open elections and nominations for officers and members of the Board involving all of its participating dentists so as to give the participating dentists representation in matters relating to improvement of patient services and maintaining high professional standards, and be it further 87 For AGD Constituent Use Only Resolved, that this resolution be conveyed to the ADA House of Delegates for implementation." To be owned and operated by licensed dentists 86:32-H-7 2009:300-H-7 AMENDED HOD 2009 “Resolved, that policy 86:32-H-7 be amended so that it reads:” 86:32-H-7 “Resolved, that the AGD recognize that the public is best served when dental practices (those traditional fee for service private practices or any alternative compensation system of practice) are owned and operated by dentists licensed in the state or province of such ownership or operation, and be it further Resolved, that the AGD supports the inclusion of language in state dental practice acts that would prohibit a party or parties not licensed to practice dentistry from becoming involved in the ownership or control of dental practices with an exception allowing for the non-dentist survivor or designee of a deceased dentist to retain ownership of the dental practice in order to facilitate an orderly transfer of patient records to a new dentist owner or licensed dental practice with ownership to remain in effect until an orderly transfer can occur or a two year period from the death of the original dentist owner.” Dental Students Financial assistance to, that restricts choice of geographical location of practice 76:50-H-11 "Resolved, that the AGD oppose any form of federal assistance to dental schools or dental students that restricts the freedom of graduates of dental schools to voluntarily choose the type or the geographical location of their practices, as long as they are able to meet the appropriate state licensing requirements." Loan program for 81:23-H-7 "Resolved, that AGD recognize the need for the dental profession to offer input into a fair and equitable loan program for dental students, supported by both private and public funds." 81:36-H-7 "Resolved, that AGD recognize the need to have the federal government involved in providing loans to dental students with the provision that all such funds be paid back with appropriate interest." Recruiting highly qualified students 88 For AGD Constituent Use Only 87:56-H-7 "Resolved that the AGD urge its constituent Academies to continue their involvement with dental schools and alumni associations in recruiting highly qualified students for dental schools." Requiring dental students to repay government capitation loans made to schools *75:37-H-10 RESCINDED Denturism 85:24-H-7 "Resolved, that in the interest of the health of the public, the Academy of General Dentistry supports the need of the dentists to be appropriately involved in all dental and oral prosthetic care rendered directly to patients, and as such, opposes the denturism movement." Direct Reimbursement Definition of 90:56-H-7 "Resolved, that 'direct reimbursement' be defined as follows: '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.'" Promotion of 85:28-H-7 "Resolved, that the Academy of General Dentistry continue its support of the American Dental Association's efforts and activities to promote direct reimbursement throughout the country." 97:27-H-8 “Resolved, that the Academy of General Dentistry is in support of and offers encouragement to the ADA in its efforts to promote direct reimbursement.” Dues Assessment 81:48-H-7 "Resolved, that the Board include an enumeration of any portion of the membership to be suggested for exemption from a future assessment along with its complete rationale for any assessment to be considered in the future by this House of Delegates." 89 For AGD Constituent Use Only 2005:13H-H-7 Resolved, that the Academy of General Dentistry recommends that dentists receive training on the recognition and evaluation for signs and symptoms consistent with abuse and/or neglect. Enteral Conscious Sedation 2006:1-H-8 “Resolved, that the AGD adopts as policy, the White Paper on Enteral Conscious Sedation.” Federal Services Benefits for military personnel and their dependents 81:38-H-7 "Resolved, that the AGD support the concept of enhancing the benefits offered to individuals serving in the military by providing dental services for their dependents, and be it further Resolved, that these dental services shall be provided by the private sector where possible, and be it further Resolved, that the AGD work to have provisions under which these services are to be provided conform to AGD policy." Salary reimbursement for military dentists 81:25-H-7 "Resolved, that AGD recognize that factors such as the following items should be taken into consideration in the salary reimbursement for federal service dentists: o o o o o o 91:50-H-7 the amount of education acquired by the dentist the proficiency of the dentist the level of experience of the dentist and the individual's ability to handle the more complex dental procedures in a competent manner status, rank, or duties within the group tenure the cost of living in one geographical area as opposed to another." "Resolved, that the salaries for physicians and dentists in the Federal Services should be determined by the following factors: 1. The scope of responsibility which may be determined by rank, title, etc. 2. The degree of education which may include specialty training, general practice residencies, advanced educational programs in general dentistry, passage of a certifying board, etc. 3. A relationship with the remuneration generally earned by that profession within the practicing civilian sector. 4. Length of service." 90 For AGD Constituent Use Only Special pay for uniformed services 93:31-H-7 "Resolved, that the Academy of General Dentistry support the upgrading of special pay for dentists in the federal uniformed services, and that this position be properly communicated to the American Dental Association." Fees Adjusted for complying with governmental regulations 92:35-H-7 "Resolved, that the Academy of General Dentistry recommends that dentists may incorporate into their normal overhead the cost of complying with OSHA, CDC and other government regulations, and be it further Resolved, that dentists may charge a separate fee or adjust current fees to cover these costs." General Dentist Continued competency 94:24-H-7 "Resolved, that assuring the public of the dental profession's continued competency is best addressed by appropriate continuing dental education, effective peer review, and the proper enforcement of the dental practice acts by the state and provincial boards of dental examiners, and be it further Resolved, that the AGD of General Dentistry continue to express this position by letter to members of the American Association of Dental Examiners Continued Competency Committee and the American Association of Dental Examiners Executive Council before the final presentation of the Continued Competency report, and be it further Resolved, that the Academy of General Dentistry express this position by letter to the American Dental Association, the American Dental Education Association and all other individuals and organizations that would be affected by or have influence on this issue." Creed of 84:17-H-7 "Resolved, that the Academy of General Dentistry establish a creed for the purpose of more closely identifying the organization with a philosophy and code of conduct, and be it further Resolved, that the following five statements be adopted as the AGD creed: 1. To educate myself to perform with greater ability. 2. To provide and promote the best treatment for my patients. 91 For AGD Constituent Use Only 3. To treat my patients with continued dignity and empathy. 4. To share my knowledge with my patients and my profession. 5. To maintain my integrity and professionalism. And be it further Resolved that if feasible, the AGD creed be included on the back of the AGD membership cards and used in such other ways determined to be appropriate." Coordinate and manage dental health 82:22-H-7 "Resolved, that the AGD recognizes that it is in the best interest of the public for the general dentist to coordinate and manage the oral health care needs of all patients." Definition of *83:17-H-7 RESCINDED *82:33-H-7 RESCINDED 84:16-H-7 RESCINDED HOD 2007 2007:303-H-6 AMENDED HOD 2008 2008:319S-H-7 2009:310-H-7 AMENDED HOD 2009 “Resolved, that the AGD amend policy 2008:319S-H-7. “Resolved, that Policy 2007:303-H-7 be amended so that it reads: 2007:303-H-7 “Resolved, that policies 82:33-H-7 and 84:16-H-7 be rescinded, and be it further Resolved, that AGD defines a general dentist as 'An individual who has successfully completed formal dental training leading to a DDS, DMD, or comparable degree which qualifies that individual to be a dentist and to accept the professional responsibility for the diagnosis, treatment, management, and overall coordination of services that meets patients' oral health needs, and who has not announced a limitation of practice to any of the specialty areas recognized by the American Dental Association,’ and be it further Resolved, that the AGD defines 'primary dental care provider' as 'the general or pediatric dentist who accepts the professional responsibility for 92 For AGD Constituent Use Only the treatment of the patient and/or the management and coordination of services to meet the patient's oral health needs, consistent with the ADA Principles of Ethics and Code of Professional Conduct.” Parity with physicians in all remuneration 75:39-H-10 RESCINDED HOD 2008 2008:302-H-7 “Resolved, that policy 75:39-H-10 is rescinded.” Primary dental care provider, defined 95:8-H-7 "Resolved, that the AGD define 'primary dental care provider' as 'the general or pediatric dentist who accepts the professional responsibility for the treatment of the patient and/or the management and coordination of services to meet the patient's oral health needs, consistent with the ADA Principles of Ethics and Code of Professional Conduct,' and be it further Resolved, that policy 82:33-H-7 be rescinded." Primary entry point into dental care system 75:38-H-10 "Resolved, that the AGD endorse the concept of having the patient's entry level into the dental health care delivery system be through the general practitioner, and be it further Resolved, that it be the general practitioner's prerogative to determine when and if a patient should be referred to another source for his dental treatment, and be it further 82:21-H-7 "Resolved, that the AGD recognizes that it is in the best interest of the public for the general dentist to be the primary entry point into the dental care delivery system." Resolved, that the AGD advocate this position in programs involving federal and state governments as well as insurance companies so that optimal dental health care will be more readily available to larger segments of the public at less cost." General Practice Residency Program 79:32-H-6 "Resolved, that the AGD support general practice residency programs, and be it further Resolved, that the AGD recommend that a significant portion of the content of all general practice residency programs be devoted to but not limited to experience in a hospital environment, and be it further 93 For AGD Constituent Use Only Resolved, that the AGD recognizes the concept of and the need for the general dentistry residency." Commission on accreditation urged to require that directors of GPR's be general dentists 80:33-H-7 "Resolved, that the ADA Commission on Dental Accreditation be urged to require that, in the future, the directors of general practice residency programs and advanced educational programs in general dentistry be well-qualified general dentists." Geriatric Care 76:54-H-11 "Resolved, that the AGD recognizes the importance of dental care for the geriatric patient, and recommends that constituent academies through state dental societies institute whatever means necessary to inform the geriatric patient of the importance of regular dental care, and to aid in the providing of that care to economically disadvantaged geriatric patients." Health Maintenance Organizations (HMO’s) Providing funds for HMOs 75:40-H-10 2008:303-H-7 RESCINDED HOD 2008 "Resolved, that policy 75:40-H-10 is rescinded.” Health Planning Organized dentistry to provide input for 81:39-H-7 "Resolved, that the AGD recognize the need for appropriate health planning, and be it further Resolved, that the AGD support the concept of organized dentistry having input into health planning, and be it further Resolved, that the AGD support the concept of using local funds for health planning, and, when necessary, state and federal funds." Support to repeal Health Planning Act *81:22-H-7 RESCINDED HOD 7/2000 HIV HIV-infected patients, policy on "Resolved, that the AGD regards HIV-infected patients as medically 94 For AGD Constituent Use Only 88:50-H-7 compromised individuals with an infectious disease who deserve the most considerate and scientifically sound dental care available and be it further CLAUSE RESCINDED HOD 7/99 Resolved, that the AGD vigorously opposes state and/or federal laws and regulations that would classify persons with infectious diseases as handicapped, and be it further Resolved, that the AGD opposes dental care discrimination against any individual, including those with infectious diseases." HIV testing of dental personnel *88:49-H-7 RESCINDED Statement on disclosure and infection control 91:51-H-7 REVISED HOD 7/99 "Resolved, that the Academy of General Dentistry strongly supports the validity and use of universal precautions and appropriate sterilization procedures as techniques that greatly reduce the risk of transmission of the Hepatitis (HBV) and Human Immunodeficiency (HIV) viruses between health care workers and patients, and be it further Resolved, that the AGD supports voluntary testing of health care providers for HBV and HIV in the appropriate settings, but opposes mandatory testing because it is impractical and ultimately ineffective as a preventive measure, and be it further Resolved, that dentists and other health care personnel who believe they are infected with HIV or HBV should obtain medical advice and, if found to be infected, should act upon that advice and submit to regular medical supervision, and be it further Resolved, that the AGD work to educate the public on the safety of dental procedures and the techniques used by dental professionals to safeguard patients' health, and be it further Resolved, that policy #88:49-H-7 be rescinded." Hospital Dentistry Privileges *85:22-H-7 RESCINDED Implants *75:41-H-10 RESCINDED *75:42-H-10 RESCINDED 95 For AGD Constituent Use Only 91:47-H-7 "Resolved, that the AGD House of Delegates agrees that oral implant therapy can be an acceptable mode of clinical treatment when indicated, and be it further Resolved, that policy 75:41-H-10 be rescinded." *92:31-H-7 RESCINDED HOD 7/96 96:53-H-7 "Resolved, that as an adjunct to the AGD's existing policy with regard to the consideration of implant dentistry as a specialty, that the following principles be adopted: 1. The AGD actively supports the policy that all qualified dentists be permitted to perform all aspects of implant dentistry including placement and restoration. 2. The AGD believes that it is in the public's best interest that oral implantology not be limited to one discipline of dentistry. 3. The AGD opposes the implication that specialists performing oral implants are also specialists in implantology 4. The AGD opposes any marketing efforts that imply any provider of implants is a qualified oral implantology specialist and be it further, Resolved, that Policy 92:38-H-7 be rescinded." Pre-doctoral education 92:32-H-7 "Resolved, that the AGD support pre-doctoral education in the diagnosis, placement and restoration of oral implants in the curricula of all dental schools, and be it further Resolved, that this resolution be transmitted to the ADA House of Delegates and to the American Dental Education Association." Infection Control Measures Urged *87:64-H-7 RESCINDED HOD 7/99 Infectious Waste State and government regulation 90:55-H-7 "Resolved, that the AGD recognize that state law and government regulation is determining the definition and handling of infectious waste, and be it further 96 For AGD Constituent Use Only Resolved, that when evaluating the merit of such regulations, the AGD primarily will be concerned about the safety of the public, and also will insist that the regulations be based on scientific validity with appropriate consideration given to cost effectiveness." Insurance, Malpractice 84:24-H-7 "Resolved, that the Academy of General Dentistry continue to support the American Dental Association's three-classification system for malpractice insurance until such time as evidence has been presented to indicate that there is merit in going to another system." Legislation Access to dental care Incentives for dentists to practice in underserved areas 2001:29-H-8 “Resolved, that the Academy of General Dentistry believes that in order to encourage dentists to practice in underserved areas, the following must occur: a. The period over which student loans are forgiven must be extended to 10 years, without a tax liability for the amount forgiven in any year. b. Tax credits must be provided for establishing a dental practice in said areas. c. Scholarships must be offered to dental students in exchange for serving in said areas. d. Federal loan guarantees must be provided for the purchase of dental equipment and materials. e. Appropriations for funding an increase in the number of dentists serving in the National Health Service Corps must be enacted. f. Active recruitment of applicants for dental schools from underserved areas.” 97 For AGD Constituent Use Only Legislative agenda for providing 2001:28-H-8 REVISED HOD 7/2002 “Resolved, that the Academy of General Dentistry believes that any effort to get the necessary personnel to improve access to and utilization of dental care for indigent populations will be multifactoral and complex, and includes but is not limited to the following items (understanding that these items are not prioritized and will vary from state to state): a. Take steps to facilitate effective compliance with governmentfunded dental care programs to achieve optimum oral health outcomes for indigent populations. i. ii. iii. iv. v. vi. vii. viii. ix. x. b. raise fees to at least the 75th percentile of fees which dentists currently charge eliminate extraneous paperwork simplify Medicaid rules mandate prompt reimbursement educate Medicaid officials regarding the unique nature of dentistry provide block grants to states from the federal government for innovative programs require mandatory annual dental examinations for children entering school (analogous to immunizations) to determine their oral health status encourage education of patients in proper oral hygiene and in the importance of keeping scheduled appointments utilize case management to ensure that the patients are brought to the dental office increase general dentists’ understanding of the benefits of treating the indigent Establish Alternative Oral Health Care Delivery Service Units i. ii. iii. provide oral health care, education, and preventive programs in schools arrange for transportation to and from the centers solicit volunteer participation from the private sector to staff the centers c. Encourage private organizations such as Donated Dental Services, fraternal organizations, and religious groups to establish and provide service d. Provide Mobile and Portable Dental Units to service the underserved and indigent of all age groups 98 For AGD Constituent Use Only e. Identify educational resources for dentists on how to provide care to pediatric and special needs patients and increase AGD dentist participation f. Provide information to dentists and their staffs on cultural diversity issues which will help them reduce or eliminate barriers to clear communication and enhance understanding of treatment and treatment options g. Pursue development of a comprehensive oral health education component for public schools’ health curriculum in addition to providing editorial and consultative services to publishers of primary and secondary school textbooks h. Increase supply of dental assistants and dental hygienists i. Strengthen alliances with ADEA and other professional organizations j. Expand the role that retired dentists can play in providing service to the indigent.” White Paper on Increasing Access to and Utilization of Oral Health Care Services 2008:323-H-7 “Resolved, that the AGD adopt the White Paper on Increasing Access to and Utilization of Oral Health Care Services.” AGD opposes limiting political or PAC contributions 87:53-H-7 "Resolved, that the Academy of General Dentistry opposes federal legislation reducing limits on political action committee contributions to candidates for elected office." Air Force Assistant Surgeon General, Rank of 98:25-H-7 2008:312-H-7 RESCINDED HOD 2008 “Resolved, that policy 98:25-H-7 be rescinded.” Cash method of accounting, not accrual 98:26-H-7 “Resolved, that the Academy of General Dentistry support the use of the cash method of accounting, and not the accrual method, where preferred, by 99 For AGD Constituent Use Only dentists engaged in the private practice of dentistry, and be it further Resolved, that the Academy of General Dentistry communicate this position, when necessary, to legislative and regulatory entities.” Community Health Centers 2003:15A-H-7 “Resolved, that the AGD recognizes that Community Health Centers can be a component in the effort to increase access to oral health care if the Community Health Center Board partners with local dental societies in order to contract with locally practicing dentists and more adequately identifies and reaches underserved and indigent (defined as 150% of the Federal Poverty Level) populations, and be it further Resolved, that appropriate legislative activity be pursued to ensure that Community Health Centers are properly funded and function in the manner for which they were intended.” Deduction for member dues 87:55-H-7 "Resolved, that the AGD support legislation and seek coalitions with other professional organizations that will allow salaried professionals to fully deduct dues to professional organizations without having to exceed the 2% of adjusted gross income now required for deduction of miscellaneous tax deductions." Dental Lab Disclosure 2008:320RS1-H-7 "Resolved, that the Academy of General Dentistry support legislation that requires dental labs to provide written disclosure to dentists the place of fabrication and the specific composition of all materials used in the fabrication of dental restorations and appliances.” Federal Trade Commission 88:51-H-7 "Resolved, that the Academy of General Dentistry has a high priority in urging every member of Congress to join in the adoption of legislation that would restrict the Federal Trade Commission from intervening in state-regulated professions." FTC's efforts to pre-empt state laws re corporate ownership 86:31-H-7 AMENDED 2008:309-H-7 2008:309-H-7 “Resolved, that policy 86:31-H-7 be amended so that it reads: 100 For AGD Constituent Use Only "Resolved, that in the interest of safeguarding patient care and freedom of choice, the AGD opposes any efforts by the Federal Trade Commission and any other agencies to preempt state laws that prohibit non-dentist owned corporate dental practices, and be it further Resolved, that the AGD supports any efforts to challenge the Federal Trade Commission's and any other agency's statutory authority to preempt state laws regarding non-professional, non-provider ownership of health care practices." General Practitioner's role as gatekeeper for oral health 2008:316-H-7 “Resolved, that the AGD as an organization of general dentists make every effort to inform policy makers of the potential effect increased specialization of dentists will have on the fragmentation of dentistry, especially on rural communities’ access to oral health care.” Government relations manager *85:29-H-7 RESCINDED HOD 7/99 "Resolved, that the House of Delegates endorses the action of the Board of Trustees in its efforts to maintain and strengthen the general practitioners' representation in Washington by having the AGD's Executive Director hire a Government Relations Manager, to the staff of the AGD, to be housed in the same building as the Washington office of the American Dental Association, on a pilot basis." Government subsidized health care programs 78:21-H-6 "Resolved, that AGD oppose all programs that allow government subsidized health care delivery systems to compete unfairly with the private practice delivery system, and be it further Resolved, that the Council on Legislation direct their efforts in concert with the appropriate councils of the ADA and their constituent legislative councils to gather and disseminate all information which deals with this issue to the appropriate leadership at the national and state levels, and be it further Resolved, that the leadership in the profession at national and state levels make every effort to upgrade the information deficit of federal and state legislatures so that they may be fully informed." Guidelines for dealing with state legislation 89:54-H-7 "Resolved, that the Academy of General Dentistry use the following guidelines in dealing with members requesting AGD action on legislation being proposed in their state: 101 For AGD Constituent Use Only 1. Members have the right to know existing policies. 2. The AGD will not intervene in the legislative affairs of a state or province without the written request of the constituent AGD. 3. Members requesting support from the AGD for a legislative position will be asked to work through their constituent. 4. Constituent secretaries/executive directors and Trustees will be provided with copies of AGD correspondence with their members regarding concerns about legislative issues being considered." Indigent population, AGD as a voice for the 2003:15B-H-7 AMENDED 2008:310RS-H-7 2008:310RS-H-7 “Resolved, that policy 2003:15B-H-7 be amended so that it reads: “Resolved, that the AGD continue to be an advocate for the oral health of the general population, including but not limited to the underserved. Language interpretation at provider’s expense 2001:31-H-8 “Resolved, that the Academy of General Dentistry is opposed to any federal, state or local government mandate that would require a dentist or other health care provider to supply, at the provider’s expense, language interpretation for patients who do not speak English or who have limited proficiency with the English language.” Legislative or regulatory mandates with inadequate scientific basis 2000:30-H-7 “Resolved, that the Academy of General Dentistry oppose any legislative or regulatory mandate affecting the practice of dentistry which is based on principles that do not have adequate scientific basis as determined by the AGD.” Link between periodontal disease and low birth-weight babies 2003:14-H-7 “Resolved, that the Academy of General Dentistry supports legislation that seeks to increase accurate and up-to-date professional and public awareness of the link between periodontal disease in pregnant women and pre-term, low-birth weight babies and the maternal transmission of caries.” Luken Lee Amendment, endorsement of ADA's position 102 For AGD Constituent Use Only *82:29-H-7 RESCINDED HOD 7/99 Managed care, AGD’s legislative priorities regarding 97:29-H-8 “Resolved, that the AGD’s legislative priorities with regard to dental managed care encompass the following: Patients will have the choice to select a plan with a point-of-service option, with reasonable cost-sharing requirements in premiums and per-service costs provided that those costs are not excessive. Patients in a plan will be allowed to select their dentist, and change that selection as the patient feels is necessary. The plan shall provide access to an adequate mix and number of dentists, including both general dentists and specialists, to ensure access to those services covered by the plan C including patients in rural and dentally under-served areas. The plan shall allow patients with special needs to be referred to appropriate providers including specialists. The plan shall provide an appropriate appeals and grievance procedure that allows for timely responses to patient and/or provider complaints. The plan shall provide a dentist, licensed to practice in that state or province where the services are provided, to be responsible for dental treatment policies, protocols, and quality assurance activities. The plan shall define and disclose limitations on coverage of experimental treatments and provide timely written justification for denial of such treatment to patients. The plan shall not discriminate in participation, reimbursement, or indemnification against any dentist solely on the basis of his/her license. The plan shall not prohibit or limit a dentist or other health professional from engaging in communications regarding the patient’s health status, health care, treatment options, or utilization review requirements. The plan shall not provide any financial incentives to dentists, other health professionals, or reviewers to deny or limit care. 103 For AGD Constituent Use Only The plan shall provide dentists with reasonable notice of termination and allow the dentist to appeal such a decision and take corrective action if necessary. The plan shall assume any liability resulting from the plan’s denying or restricting treatment or referral to specialists.” Mandating national licensure 76:49-H-11 2008:311-H-7 RESCINDED HOD 2008 “Resolved, that policy 76:49-H-11 is rescinded. Mandating preferred provider organizations 84:25-H-7 "Resolved, that the Academy of General Dentistry oppose any federal legislation for the purpose of mandating preferred provider organizations, or pre-empting state laws that regulate preferred provider organizations." Military dentists, special pay and incentives for 2001:30-H-8 “Resolved, that the Academy of General Dentistry request immediate action to stem the exodus of current military dental officers and assure a continuing supply of quality accessions, and be it further Resolved, that the AGD favor increasing additional special pay, establishing incentive pay for dentists, and increasing Health Professions Scholarship Program (HPSP) scholarship funding.” National Practitioner Data Bank 90:57-H-7 "Resolved, that the Academy of General Dentistry work with the ADA to urge Congress and the Department of Health and Human Services to amend the National Practitioner Data Bank so that it will include only information on suspension of license, revocation of license or loss of hospital privileges for disciplinary reasons, and be it further Resolved, that the following resolution adopted by the 1989 AGD House of Delegates be rescinded: 1989-40R. 'Resolved, that the Academy of General Dentistry urge Congress and the Department of Health and Human Services, both directly and through the American Dental Association, to abandon the National Practitioner Data Bank because of its potential for abuse, its high cost of implementation, its impact on peer review and its lack of regard to the overall quality and total volume of care provided.'" 104 For AGD Constituent Use Only NIDCR 2003:18-H-7 “Resolved, that the Academy of General Dentistry supports the continued existence and current structure and mission of the National Institute of Dental and Craniofacial Research, and be it further Resolved, that the AGD will take appropriate steps to lobby in support of NIDCR.” Nitrous oxide inhalation sedation 94:18-H-7 “Resolved, that the Academy of General Dentistry supports the use of scavenging equipment for nitrous oxide, and be it further Resolved, that any additional regulation of nitrous oxide be based on valid scientific documentation.” Prohibiting latex use without documented scientific evidence 98:22-H-7 “Resolved, that the Academy of General Dentistry be directed to oppose any legislation or regulation that is not based on documented scientific evidence of significant general risk to dental patients or workers which would prohibit the use of latex or latex-containing products in the dental office.” Protect dental insurance as a fringe benefit 81:24-H-7 AMENDED 2008:306-H-7 2008:306-H-7 “Resolved, that policy 81:24-H-7 be amended so that it reads: "Resolved, that the AGD work to ensure that legislation would not adversely affect an employer's decision to provide dental insurance.” 83:24-H-7 2008:307R-H-7 AMENDED 2008:307R-H-7 “Resolved, that policy 83:24-H-7 be amended so that it reads: “Resolved, that the AGD resist efforts being made by third party dental benefits programs to prohibit payment based on the specific technique used by the dentist to render treatment for the patient.” Public disclosure of information in National Practitioner Data Bank 105 For AGD Constituent Use Only 2000:27-H-7 “Resolved, that the AGD oppose public disclosure of National Practitioner Data Bank information because it has the potential to provide misleading information about physician and dentist competency.” Public Health Service Surgeon General 96:55-H-7 "Resolved, that the Academy of General Dentistry recommends and supports continued and ongoing Congressional funding of the Office of the Surgeon General of the United States Public Health Service in order to fulfill the mission of administration and oversight of the Commissioned Corps of the USPHS, and be it further Resolved, that the AGD supports the appointment of the Surgeon General from the ranks of the Commissioned Corps of the USPHS in keeping with existing legislation that provides for this result." Sales tax on professional services - AGD opposition 87:63-H-7 "Resolved, that the AGD recommend that its constituents work with ADA and Canadian dental societies in opposing sales taxes on professional fees and services." State over federal regulation of the dental profession 82:30-H-7 "Resolved, that the AGD supports the principle that in any regulation of the dental profession the dental health interests of the public are better served by the state rather than federal regulation." Student Loan Interest Deduction 87:54-H-7 "Resolved, that the AGD support legislation seeking reinstatement of the full tax deductibility of interest payments of student loans." Tax credit in states with reimbursement rates below 75th percentile 2004:15-H-7 "Resolved, that the Academy of General Dentistry seeks a tax credit not to exceed $5000 for dentists participating in the Medicaid program in states where reimbursement rates are less than the 75th percentile, and be it further Resolved, that the credit be calculated on the difference between the state Medicaid reimbursement rate and the most recent ADA Annual Fee Survey 75th percentile schedule for the region." Tobacco Cessation Treatment 106 For AGD Constituent Use Only 2008:313-H-7 “Resolved, that treatment for tobacco cessation including appropriate medication is within the scope of dental practice, and be it further Resolved, that constituents be encouraged to lobby state and provincial legislatures/dental boards where restrictions exist.” Tobacco settlement earmarked for health care 2000:29-H-7 “Resolved, that the AGD support having monies from the settlement with the tobacco industry be earmarked for health care and be it further Resolved, that this position be communicated to constituent AGD presidents who should work with state dental associations to see this is implemented in their respective states.” Veterans Administration Dental Director 96:57-H-7 RESCINDED HOD 2008 2008:305-H-7 “Resolved, that policy 96:57-H-7 is rescinded.” Water quality during routine dental treatments should be appropriate 2000:28-H-7 “Resolved, that the AGD supports the use of appropriate water quality during routine dental treatments.” Licensing Limited to dentists and dental hygienists 73:22-H-10 "Resolved, that there be no additional licensing of personnel in the dental health field other than the dentist and the dental hygienist." Licensure By credentials 92:33-H-7 "Resolved, that the Academy of General Dentistry encourage the American Dental Association and the Canadian Dental Association to advocate a position that will encourage the various states or provinces to allow graduates of dental schools accredited by the Joint Commission on Accreditation of Dental Schools to be licensed by credentials in other states or provinces by meeting these criteria as a minimum: 1. Having successfully passed the National Boards and 107 For AGD Constituent Use Only 94:19-H-7 2. Having passed a State or Provincial Board of Dental Examiners exam and/or a regional licensure exam 3. Having satisfactorily completed a jurisprudence and/or law exam if required by that state or province and 4. Having satisfactorily complied with the state or provincial law and Principles of Ethics of the state or province in which the individual is currently practicing." "Resolved that the Academy of General Dentistry actively support licensure by credentials by providing assistance to any region or constituent requesting support in promoting the issue at the state level." Limitation of Practice *72:10-H-10 RESCINDED HOD 7/2004 Malpractice Insurance and Litigation Defending their capabilities to render dental procedures 81:12-H-7 "Resolved, that members faced with problems of defending their capabilities to render certain dental procedures be advised to seek help from local general practitioners to serve as expert witnesses on their behalf, and be it further Resolved, that the AGD assist individual members in need of credentials by providing them with letters which may indicate any of the following points: A. The fact that the individual has been a member in good standing of the AGD since a specific date. B. The number of hours of continuing education on record in the AGD's central office for the member. C. Verification that the individual has achieved Fellowship or Mastership status in the AGD. D. Any of the individual's activities as a member, including the committees he has served on and the offices he has held in the AGD." Mandated Health Benefits AGD policy on 87:51-H-7 "Resolved, that the Academy of General Dentistry opposes federal and state laws mandating health and related benefits because such laws may increase 108 For AGD Constituent Use Only health care costs, reduce employers' incentives to hire full-time staff members, increase a trend toward underemployment of auxiliaries, and reduce incentives for employers to provide health care benefits since such laws place solo and small group practitioners at an economic disadvantage, and be it further Resolved, that Congress and the states should explore alternatives to government-mandated benefits, including favorable tax incentives that encourage employer expansion of health care and related benefits." National Health Program, Dentistry’s Position on *77:20-H-6 RESCINDED HOD 7/94 National Practitioner Data Bank 94:17-H-7 "Resolved, that the Academy of General Dentistry recommends limiting access to the National Practitioner Data Bank to those persons and entities originally authorized to report to and query the data bank by the Health Care Quality Improvement Act of 1986." OSHA AGD efforts to control regulations relating to infectious waste control 89:57-H-7 "Resolved, that the AGD work with the ADA in negotiating with OSHA and other governmental agencies to make regulations involving infection control, hazard communication and infectious waste less onerous and more economical for the general public and the dental profession." AGD influence in adopting guidelines 89:52-H-7 "Resolved, that the Academy of General Dentistry work to influence the formation of OSHA guidelines that would protect the privacy and quality of patient care during the time of office inspection, and be it further Resolved, that the Academy of General Dentistry request the ADA to include the following points in its negotiations with OSHA: 1. Inspectors should allow normal office operation to continue during inspection. 2. Inspectors should not interfere with patient care. 3. Inspectors should not attempt to speak with a dentist who is engaged in direct patient care or consultation with a patient. 4. Inspectors should not invade or in any way compromise a patient's privacy or confidentiality. 109 For AGD Constituent Use Only 5. Inspectors should not make comments to a dentist, staff or other inspectors within patients' hearing." AGD supports the ADA’s position on OSHA’s anticipated rule on Workplace Safety & Health Programs 97:28-H-8 “Resolved, that the AGD support the ADA’s position on OSHA’s anticipated proposed rule on Workplace Safety & Health Programs as outlined in the letter written by Dr. William S. TenPas and attached to this report as Addendum A. The AGD specifically supports an exemption in any final OSHA regulation on Workplace Safety & Health Programs for both small employers and low risk employers.” Worker safety regulation, opposition 93:30-H-7 "Resolved, that the Academy of General Dentistry work in conjunction with the American Dental Association to oppose any OSHA worker safety regulations that are not substantiated by scientific documentation." Patient Records Confidentiality of 78:22-H-6 "Resolved, that the Academy of General Dentistry support the principle of maintaining the confidentiality of patients' dental records, and be it further Resolved, that the Academy of General Dentistry considers the compulsory in-office audit of dental offices to be an invasion into the confidentiality of patients' dental records." Pediatric Dentistry Defined 95:7-H-7 "Resolved, that the Academy of General Dentistry supports the adoption of the following revised definition of the specialty of pediatric dentistry: 'Pediatric dentistry is an age-defined specialty that provides primary, comprehensive, preventive and therapeutic oral health care for infants and children through adolescence, and may also include the treatment of those with special health care needs.'" Peer Review Committees For general dentists 77:11-H-6 "Resolved, that the peer review mechanisms of organized dentistry be the 110 For AGD Constituent Use Only sole factor in determining whether a dentist is qualified to perform a particular dental service, and be it further Resolved, that the AGD vigorously oppose the formation of lists of dental services which might indicate that a general dentist is not qualified to perform certain procedures." PSROs (Professional Standards Review Organizations) *73:19-H-10 RESCINDED HOD 7/99 Quality control review by 76:30-H-11 "Resolved, that the AGD endorses quality control review in the United States only by peer review committees established by ADA constituents and rejects the concept that quality review is the prerogative of prepayment programs." Seek general practitioner representation on *75:25-H-10 RESCINDED HOD 7/99 Post Graduate Training Availability for all recent graduates 92:36-H-7 "Resolved that the Academy of General Dentistry support, with the American Dental Education Association, the development of one-year postgraduate training programs accessible to all dental school graduates, and be it further Resolved, that the program(s) incorporate the following concepts: a) that the program should be in the category of post-graduate education with an appropriate stipend, and should not be a fifth year of dental school with potential for increased student indebtedness. b) that the program should prepare a dentist for private practice, incorporating both clinical skill enhancement and practice management training. c) that the Commission on Dental Accreditation should develop and implement appropriate standards and criteria for such one-year postgraduate training program, including the definition of credentials required of program directors. d) that program(s) be developed with sufficient flexibility for operation in the offices of selected practitioners, indigent care centers or public health sites. 111 For AGD Constituent Use Only e) that participants in post graduate training at public health sites be eligible for debt repayment programs, and be it further Resolved that the AGD's position be communicated in writing to both the ADA's Commission on Dental Accreditation and to the American Dental Education Association." Public Information Monitoring dental health messages to the public 98:20-H-7 “Resolved, that AGD monitor dental health messages communicated to the public in an effort to see that the interest of the general dentist is properly reflected.” Radiographs Dental assistants must be properly trained to use 80:23-H-7 "Resolved, that AGD recognizes that dental assistants should be properly trained to safely utilize radiological equipment, and be it further Resolved, that AGD recognizes the need to have dental radiological equipment appropriately monitored in order to ensure the safety of the public, and be it further Resolved, that AGD encourages the ADA to establish a comprehensive radiological safety program." Submission to insurance carriers *75:26-H-10 RESCINDED 76:56-H-11 RESCINDED HOD 7/2006 2006:22R-H-7 “The AGD endorses the most current radiographic recommendations developed by the Food and Drug Administration once reviewed by the appropriate AGD agency which will serve as a guide to the general dentist’s professional judgment of how to best use diagnostic imaging tools for each patient, and be it further Resolved, that policy (76:56-H-11) At all times, decisions relating to the radiographic exposure of patients shall remain with the dental profession and shall be accomplished only when there is a benefit to the dental health of the patient be rescinded.” Salaried Dentists 90:58-H-7 "Resolved, that the AGD strongly support governmental dentists being remunerated at a level competitive with dental incomes in the civilian sector, and be it further 112 For AGD Constituent Use Only Resolved, that the AGD support legislative proposals that promote an increase in remuneration for dentists serving in the government to a level that is competitive with dentists in the civilian sector." Sedation Adequate facilities for teaching 87:57-H-7 "Resolved, that the Academy of General Dentistry use the following definition to define adequate facilities for the teaching of conscious sedation at the undergraduate and continuing dental education levels: 'An area equipped with suction, monitoring equipment, emergency drugs, and equipment to deliver oxygen under positive pressure in relatively quiet and private surroundings.'" Teaching of, at the undergraduate and CE levels 86:36-H-7 2008:204-H-7 AMENDED HOD 2008 “Resolved, that the following resolution be amended to read: “Resolved that policy 86:36-H-7 be amended so that it reads: "Resolved, that the Academy of General Dentistry supports the teaching of conscious sedation at the undergraduate and continuing education levels in dental schools and other adequate teaching facilities as defined by the AGD's Education Council.” Smoking AGD position on use of Tobacco 90:41-H-7 "Resolved, that the Academy of General Dentistry believes that the use of tobacco has a significantly adverse impact on the public's oral and general health and encourages its members and all general practice dentists and members of the dental health team to promote tobacco abstinence through patient education; and be it further Resolved, that the AGD encourages all dental offices to serve as model tobacco-free environments and to work actively within the community to promote tobacco abstinence and to educate school-age children on the hazards of tobacco use." Specialty License Laws 73:20-H-10 "Resolved, that the Academy of General Dentistry continue to oppose the creation of specialty licensure laws within various states and that state 113 For AGD Constituent Use Only Academies should remain vigilant against further expansion of these programs." 74:11-H-11 "Resolved, that the Academy of General Dentistry express its strong opposition to development of specialty license laws as part of state dental practice acts and that the AGD continue to support the position of the American Dental Association." Specialty Listings 74:5-H-11 "Resolved, that the Academy of General Dentistry urge its members to oppose specialty listings whenever proposed because of the adverse effect such a policy has on selection by the public of a general dentist as the primary vehicle of entry into the dental care delivery system." State Board of Dentistry *85:26-H-7 RESCINDED 94:16-H-7 "Resolved, that in the interest of the dental health of the public, the Academy of General Dentistry support maintaining the dental licensing authority at the State Board level, and be it further Resolved, that the Academy of General Dentistry support a single State Board(s) of Dentistry in each state, as the sole regulating authority(ies) for entry level licensure of dentists and hygienists, and be it further Resolved, that the AGD support state board examinations for entry level licensure, and be it further Resolved, that the following policy adopted by the AGD's 1985 House of Delegates be rescinded: Resolved, that in the interest of the dental health of the public, the Academy of General Dentistry supports a single State Board of Dentistry in each state, as the sole regulating authority for the delivery of dental care, and be it further Resolved that the following resolution be sent to the ADA's 1985 House of Delegates: 'Resolved, that the American Dental Association, in the interest of the dental health of the public, supports a single State Board of Dentistry in each state, as the sole regulating authority for the delivery of dental care' and be it further Resolved, that the following resolution be sent to the ADA's 1994 House of Delegates: 114 For AGD Constituent Use Only 'Resolved that the American Dental Association, in the interest of the dental health of the public, support maintaining the dental licensing authority at the State level and be it further Resolved, that the American Dental Association support a single State Board of Dentistry in each state, as the sole regulating authority for entry level licensure of dentists and hygienists', and be it further Resolved that the ADA support state board examination for entry level licensure." Sterilization Procedures 92:25-H-7 "Resolved, that the Academy of General Dentistry believes the public good is best served by sterilization procedures for the dental office that provide patients with maximum protection against any possibility of cross contamination and that demonstrate the dentist's commitment to patient health and safety, and be it further Resolved, that the AGD reaffirms its policy of sterilization by currently accepted methods, including heat sterilization of dental instruments between every patient, and be it further Resolved, that the Academy of General Dentistry work with the American Dental Association, the Canadian Dental Association, the National Dental Association, and the Centers for Disease Control to encourage all dentists to follow this policy and to raise public awareness of the safety of the dental office and the measures that ensure health and safety of the public and of all involved in dental care delivery." Surveys Of dental schools, annually 94:23-H-7 "Resolved, that the annual survey of dental schools to investigate the progress toward an academic postgraduate degree or other recognition for the general practitioner be discontinued as it is no longer effective in evaluating the activities of dental schools with regard to the training of general dentists." Table of Allowances Acceptable reimbursement mechanism 76:52-H-11 "Resolved, that the Academy of General Dentistry go on record as endorsing the table of allowances as an acceptable reimbursement mechanism." 115 For AGD Constituent Use Only VI. Access and Prevention General Since the release of the Surgeon General’s Report on Oral Health, many organizations have begun to focus on access to oral health care issues. As constituent chairperson of dental care/practice, you must be aware of means by which your constituent can become involved in ways to increase access to oral health care for the populations that you serve. There are many examples of programs at state and organizational levels that can be found by using your Internet web-browser. Go to a browser (e.g., type in the URL, www.google.com, or www.excite.com) then, in the search field type, “dental care, access.” Your search will return a plethora of reports on state programs, examples of groups banding together to provide care, legislative agendas, local clinics, and many areas where your constituent can research or become involved in access to care issues. Involvement can be at any level including support for legislative action, provision of care, aid in administration of clinics, or sitting on the boards of non-profit entities. Your efforts in the support of access to care are limited only by your collective imaginations. As leaders in our communities in the field of oral health, we must take the initiative to become problem solvers in this major health concern. William Maas, DDS, MPH, former Chief Dental Officer of the U.S. Public Health Service, believes that while community efforts by individual doctors to provide clinical care are important, it is the efforts of organizations such as the AGD and the members of its constituents that make the biggest difference. When members help in the organization and administration of urban or rural community oral health efforts, especially in the dissemination of our knowledge and organizational skills, we can multiply those talents many-fold over the impact of any of us individually. Medicaid administration, reimbursement, and utilization all need to be improved. In order to increase access to care for disadvantaged populations, active involvement at the constituent level in the area of lobbying for improvement of legislation for Medicaid programs must continue. Cumbersome regulations and paperwork, poor reimbursement rates, and poor prioritization of treatment utilization contribute to the dearth of practitioners willing to become or to continue as Medicaid providers. Making the provision of Medicaid care a more effective and rewarding experience for dentists will go a long way toward improving access to care for populations. Constituent leaders should become students of modalities that provide cost-effective and necessary preventive and restorative care for disadvantaged populations. Constituent bodies can then leverage their expertise when lobbying with local and state legislators to improve the Medicaid system. AGD Access to Care White Paper In 2008, the AGD HOD passed the White Paper on Increasing Access to and Utilization of Oral Health Care Services (White Paper). Please visit the AGD site and read/familiarize yourself with 116 For AGD Constituent Use Only the White Paper as it argues succinctly against the establishment of non-dentists (independent midlevel providers) to provide dentistry and for approximately 30 solutions to access to care that are tried and true, and must be funded in order to improve care in the United States. You will be asked to use this policy to take further action with state boards, legislators, dental organizations, the public, and other communities of interest within your constituent! Prevention The use of fluoride in the prevention of dental caries has been supported by the dental profession for years. In a study backed by the Centers for Disease Control and Prevention, dated August 17, 2001, and titled Recommendations for Using Fluoride to Prevent and Control Dental Caries in the United States, in-depth recommendations for fluoride indications and use are discussed. The report includes sections on: 1) How Fluoride Prevents and Controls Dental Cares; 2) Risk for Dental Caries; 3) Risk for Enamel Fluorosis; 4) National Guidelines for Fluoride Use; 5) Fluoride Sources and Their Effects—subsections include a) Drinking Water, b) Bottled Water, c) Fluoride Toothpaste, d) Professionally Applied Fluoride Compounds, and more; 6) Quality of Evidence for Dental Caries Prevention and Control; 7) Cost-Effectiveness of Fluoride Modalities; 8) Recommendations; and 9) Conclusion. Also included are charts showing the method of action of fluoride in remineralization of enamel and a map of state populations by percentage with access to fluoridated water supplies. Additionally, in the prevention and control of dental caries, community water fluoridation is strongly recommended. It was found that in municipal water supplies starting or continuing community water fluoridation (CWF) effectively prevents dental caries at varying levels, and conversely stopping CWF resulted in increased rates of caries in communities where that occurred. The ADA Web site also has a wealth of information. There are statements from the ADA addressing fluoride use, facts about fluoride safety, and a list of non-ADA Internet sites that provide information on fluorides and fluoridation issues. Again, as the oral health professionals in our communities, it is incumbent upon all of us to stay informed in caries and periodontal disease prevention modalities, as well as other oral health components and linkages to overall health. Our offices can be centers for the dissemination of learning materials for our patients that are geared toward their levels of understanding. The Dental Practice Council is actively involved in improving health literacy for various populations. Further developments are forthcoming. 117 For AGD Constituent Use Only VII. Workforce / Independent Midlevel Providers As a constituent leader, you will undoubtedly be faced with proposals or discussions in your state regarding whether to implement non-dentists working without the direct supervision of a dentist to provide care to patients. However, certain care falls within the scope of dentistry and should require the minimal education of a dentist to engage in. You will be asked to stand up and be the voice of your constituent for the profession of dentistry and the well-being of patients in your state. AGD HOD policy recognizes the dentist as the captain of the dental team, the person to ensure the optimal oral health of the public he or she serves, and the only dental team member with the complete education and training to form a diagnosis, create a comprehensive treatment plan, and perform irreversible procedures, surgeries, and other treatments that will physically alter the patient. Direct supervision of the dental team by the dentist is critical to ensuring the safety and well-being of the patient. The AGD believes its core principles and values are in the best interest of its patients and the profession, and it is for this reason that these principles and values will not be subject to alteration in response to outside influences and/or agendas. AGD’s individual policies on workforce are encapsulated in Section V above. However, for your convenience, please read the online summary of AGD’s policies here. VIII. Available Resources General The following pages contain information that is available to you. You may also want to use this section to store additional mailings you receive from AGD Headquarters. Resource Staff The following individual is available to you throughout your tenure as your Constituent’s Dental Care/Practice Chair. Srinivasan (Srini) Varadarajan, JD Director, Dental Practice Advocacy Academy of General Dentistry 211 East Chicago Avenue, Suite 900 Chicago, IL 60611-1999 888.243.3368, ext. 4973 312.440.4973 Direct Line 312.335.3454 Fax [email protected] 118 For AGD Constituent Use Only 119 For AGD Constituent Use Only 2010-2011 AGD Dental Practice Council The following Council members can offer assistance and guidance with constituent dental care activities. Joseph Battaglia, DMD, FAGD Chair 516 Hamburg Tpke Ste 9 Wayne, NJ 07470-2063 Office: 973.595.1888 Fax: 973.595.1353 E-mail: [email protected] Willis Hardesty, Jr., DDS, FAGD 2321 Blue Ridge Rd. Ste 103 Raleigh, NC 27607-6453 Office: 919.781.0018 Fax: 919.571.9114 E-mail: [email protected] Richard Kanter, DMD, FAGD Board Liaison 801 W. Fletcher Ave. Tampa, FL 33612-3424 Office: 813.961.1727 Fax: 813.968.7220 E-mail: [email protected] Susan Bishop, DMD, MAGD Division Coordinator 7314 N. Edgewild Dr. Peoria, IL 61614-2114 Office: 309.679.6141 Fax: 309.692.1796 E-mail: [email protected] Robert Margolin, DDS, FAGD 1 Fountain Ln Apt. 3L Scarsdale, NY 10583-4656 Office: 718.220.2020 ext. 8967 Fax: 718.960.9350 E-mail: [email protected] Myron J. Bromberg, DDS Consultant 7012 Reseda Boulevard, Suite G Reseda, CA 91335 Office: 818.345.3366 Fax: 818.345.4958 E-mail: [email protected] Dan McCauley, DDS, FAGD 1603 N. Jefferson Ave. Mount Pleasant, TX 75455-2329 Office: 903.572.3981 Fax: 903.577.0643 E-mail: [email protected] Richard Crowder, DDS 14922 W 87th Street Pkwy Lenexa, KS 66215-4159 Office: 913.322.2222 Fax: 913.825.9177 E-mail: [email protected] Anita Rathee, DDS 23101 Sherman Pl Ste 415 West Hills, CA 91307-2037 Office: 818.348.8898 Fax: 818.348.1841 E-mail: [email protected] John W. Drumm, DMD 3301 New Mexico Avenue NW, #230 Washington, DC 20016 Office: 202.244.1601 Fax: 202.244.1604 E-mail: [email protected] M. Samantha Shaver, DMD, FAGD 7926 Preston Hwy Preston Medical Ctr Ste 201 Louisville, KY 40219-3848 Office: 502.968.1412 Fax: 502.968.8797 E-mail: [email protected] Richard Dycus, DDS, MAGD 1005 E 6th St Cookeville, TN 38501-2830 Office: 931.528.7977 Fax: 931.528.7987 E-mail: [email protected] 120 For AGD Constituent Use Only Resource Materials The following resources will be available to you throughout your tenure as your Constituent’s Dental Care Chair. 1. Twice each year, a summary report noting the activities and issues of the most recent meeting of the AGD’s Dental Practice Council, will be provided to you along with pertinent information on dental care issues and the most current regional listing of constituent chairpersons available. 2. You will receive a short annual Constituent Dental Care Questionnaire or other communication from the members of the Dental Practice Council that you will be asked to respond to. You may be asked to identify and to discuss key dental care issues taking place within your state as well as the type of relationship you have with your state dental association. Your input will greatly aid the Dental Practice Council in advocating for the general dentist. 4. You will also receive updates to the Constituent Dental Care Resource Manual and other materials as warranted. 121 For AGD Constituent Use Only State Dental Association Contacts, Telephone Numbers, and Addresses Listed below are the contact names, telephone numbers, and addresses for each state dental association. Alabama Dental Association Dr. Zack Studstill Interim Executive Director 836 Washington Avenue Montgomery, AL 36104-3839 334.265.1684 (Office) 334.262.6218 (Fax) www.aldaonline.org California Dental Association Mr. Peter DuBois Executive Director 1201 K Street Sacramento, CA 95814 916.443.0505 (Office) 916.443.2943 (Fax) [email protected] www.cda.org Alaska Dental Society Mr. Jim Towle Executive Director 9170 Jewel Lake Road, Suite 203 Anchorage, AK 99502-5381 907.563.3003 (Office) 907.563.3009 (Fax) [email protected] www.akdental.org Colorado Dental Association Mr. Jim Young Executive Director 3690 S. Yosemite, Suite 100 Denver, CO 80237-1808 303.740.6900 (Office) 303.740.7989 (Fax) [email protected] www.cdaonline.org Arizona State Dental Association Mr. Kevin B. Earle Executive Director 3193 Drinkwater Boulevard Scottsdale, AZ 85251-6491 480.344.5777 (Office) 480.344.1442 (Fax) [email protected] www.azda.org Connecticut State Dental Association Ms. Carol Dingeldey Executive Director 835 West Queen St. Southington, CT 06489 860.378.1800 (Office) 860.378.1807 (Fax) [email protected] www.csda.com Arkansas State Dental Association Mr. Billy Tarpley Executive Director 7480 Hwy 107 Sherwood, AR 72120 501.834.7650 (Office) 501.834.7657 (Fax) [email protected] www.dental-asda.org Delaware State Dental Society Ms. Betty J. Dencler Executive Director The Christiana Executive Campus 200 Continental Drive, Suite 111 Newark, DE 19713 302.368.7634 (Office) 302.368.7669 (Fax) [email protected] www.delawarestatedentalsociety.org 122 For AGD Constituent Use Only 208.343.7543 (Office) 208.343.0775 (Fax) [email protected] www.isdaweb.com District of Columbia Dental Society Mr. C. Jay Brown, CAE Executive Director 502 C Street, NE Washington, D.C. 20002-5810 202.547.7613 (Office) 202.546.1482 (Fax) [email protected] www.dcdental.org Illinois State Dental Society Mr. Greg Johnson Executive Director 1010 S. Second Street P.O. Box 376 Springfield, IL 62705 217.525.1406 (Office) 217.525.8872 (Fax) [email protected] www.isds.org Florida Dental Association Mr. Daniel J. Buker, Jd, MS Executive Director 1111 E. Tennessee Street, Suite 102 Tallahassee, FL 32308-6913 850.681.3629 (Office) 850.561.0504 (Fax) [email protected] www.floridadental.org Indiana Dental Association Mr. Douglas M. Bush Executive Director P.O. Box 2467 Indianapolis, IN 46206-2467 317.634.2610 (Office) 317.634.2612 (Fax) [email protected] www.indental.org Georgia Dental Association Ms. Martha S. Phillips Executive Director 7000 Peachtree Dunwoody Road, NE Suite 200, Building 17 Atlanta, GA 30328-1655 404.636.7553 (Office) 404.633.3943 (Fax) [email protected] www.gadental.org Iowa Dental Association Mr. Lawrence F. Carl, CAE Executive Director 5530 West Parkway, Suite 100 Johnston, IA 50131 515.986.5605 (Office) 515.986.5626 (Fax) [email protected] www.iowadental.org Hawaii Dental Association Mr. Loren Liebling Executive Director 1345 S. Beretania Street, Suite 301 Honolulu, HI 96814-1821 808.593.7956 (Office) 808.593.7636 (Fax) [email protected] www.hawaiidentalassociation.net Kansas Dental Association Mr. Kevin J. Robertson, CAE Executive Director 5200 SW Huntoon Street Topeka, KS 66604-2398 785.272.7360 (Office) 785.272.2301 (Fax) [email protected] www.ksdental.org Idaho State Dental Association R. Quinn Dufurrena, DDS, JD Executive Director 1220 W. Hays Street Boise, ID 83702-5315 123 For AGD Constituent Use Only 612.767.8500 (Fax) [email protected] www.mndental.org Kentucky Dental Association Mr. Michael R. Porter Executive Director 1920 Nelson Miller Parkway Louisville, KY 40223-2164 502.489.9121 (Office) 502.489.9124 (Fax) [email protected] www.kyda.org Mississippi Dental Association Ms. Connie F. Lane Executive Director 2630 Ridgewood Road, Suite C Jackson, MS 39216-4903 601.982.0442 (Office) 601.366.3050 (Fax) [email protected] www.msdental.org Louisiana Dental Association Mr. Ward Blackwell Executive Director 7833 Office Park Boulevard Baton Rouge, LA 70809-7604 225.926.1986 (Office) 225.926.1886 (Fax) [email protected] www.ladental.org Missouri Dental Association Ms. Vicki Wilbers Executive Director 3340 American Avenue Jefferson City, MO 65109 573.634.3436 (Office) 573.635.0764 (Fax) [email protected] www.modental.org Maine Dental Association Ms. Frances C. Miliano Executive Director P.O. Box 215 Manchester, ME 04351-0215 207.622.7900 (Office) 207.622.6210 (Fax) [email protected] www.medental.org Montana Dental Association Ms. Mary McCue, Esq. Executive Director 171/2 Last Chance Gulch P.O. Box 1154 Helena, MT59624 406.443.2061 (Office) 406.443.1546 (Fax) [email protected] www.mtdental.com Michigan Dental Association Mr. Drew Eason, CAE Executive Director 3657 Okemos Road, Suite 200 Okemos, MI 48864-3927 517.372.9070 (Office) 517.372.0008 (Fax) [email protected] www.smilemichigan.com Nebraska Dental Association Mr. David J. O’Doherty Executive Director 7160 South 29th Street, Suite 1 Lincoln, NE 68516 402.476.1704 (Office) 402.476.2641 (Fax) [email protected] www.nedental.org Minnesota Dental Association Mr. Richard Diercks Executive Director 1335 Industrial Blvd. Minneapolis, MN 55413 612.767.8400 ext. 100 (Office) 124 For AGD Constituent Use Only 518.465.0044 (Office) 518.465.3219 (Fax) [email protected] www.nysdental.org Nevada Dental Association Dr. Robert Talley Executive Director 8863 W. Flamingo Road, Suite 102 Las Vegas, NV 89147702.255.4211 (Office) 702.255.3302 (Fax) [email protected] www.nvda.org North Carolina Dental Society Dr. M. Alec Parker Executive Director 1600 Evans Road Cary, NC 27513 919.677.1396 (Office) 919.677.1397 (Fax) [email protected] www.ncdental.org New Hampshire Dental Society Mr. James J. Williamson Executive Director 23 S. State Street Concord, NH 03301 603.225.5961 (Office) 603.226.4880 (Fax) [email protected] www.nhds.org North Dakota Dental Association Mr. Joseph J. Cichy Executive Director P.O. Box 1332 Bismarck,ND 58502-1332 701.223.8870 (Office) 701.223.0855 (Fax) [email protected] www.nddental.com New Jersey Dental Association Mr. Arthur Meisel, Esq. Executive Director One Dental Plaza P.O. Box 6020 North Brunswick, NJ 08902-6020 732.821.9400 (Office) 732.821.1082 (Fax) [email protected] www.njda.org Ohio Dental Association Mr. David J. Owsiany, JD Executive Director 1370 Dublin Road Columbus, OH 43215-1098 614.486.2700 (Office) 614.486.0381 (Fax) [email protected] www.oda.org New Mexico Dental Association Mr. Mark D. Moores Executive Director 9201 Montgomery Boulevard NE, Suite 601 Albuquerque, NM 87111 505.294.1368 (Office) 505.294.9958 (Fax) [email protected] www.nmdental.org Oklahoma Dental Association Ms. Lynn Means Executive Director 317 NE 13th Street Oklahoma City, OK 73104 405.848.8873 (Office) 405.848.8875 (Fax) [email protected] www.okda.org New York State Dental Association Dr. Mark J. Feldman Acting Executive Director 20 Corporate Wood Blvd., #602 Albany, NY 12211 125 For AGD Constituent Use Only Columbia, SC 29210 803.750.2277 (Office) 803.750.1644 (Fax) [email protected] www.scda.org Oregon Dental Association Mr. William E. Zepp, CAE Executive Director P.O. Box 3710 Wilsonville, OR97070-3710 503.218.2010 (Office) 503.218.2009 (Fax) [email protected] www.oregondental.org South Dakota Dental Association Mr. Paul Knecht Executive Director 804 N. Euclid, Suite 103 P.O. Box 1194 Pierre, SD 57501 605.224.9133 (Office) 605.224.9168 (Fax) [email protected] www.sddental.org Pennsylvania Dental Association Ms. Camille Kostelac-Cherry, Esq. CEO 3501 North Front St. P.O. Box 3341 Harrisburg, PA 17105-3341 717.234.5941 (Office) 717.234.2186 (Fax) [email protected] www.padental.org Tennessee Dental Association Mr. David S. Horvat Executive Director 660 Bakers Bridge Avenue, Suite 300 Franklin, TN 37067 615.628.0208 (Office) [email protected] www.tenndental.org Colegio De Cirujanos Dentistas De Puerto Rico Dra. Dalia E. Verge Quiles Executive Director 200 Calle Manuel V. Domenech Hato Rey, PR 00918 787.764.1969 (Office) 787.763.6335 (Fax) [email protected] www.ccdpr.org Texas Dental Association Ms. Mary Kay Linn Executive Director 1946 South IH-35, Suite 400 Austin, TX 78704 512.443.3675 (Office) 512.443.3031 (Fax) [email protected] www.tda.org Rhode Island Dental Association Ms. Valerie G. Celentano Executive Director 875 Centerville Commons, Bldg. 4, Suite 12 Warwick, RI 02886 401.825.7700 (Office) 401.825.7722 (Fax) [email protected] www.ridental.com Utah Dental Association Mr. Monte Thompson Executive Director 1151 East 3900 South, Suite 160 Salt Lake City, UT 84124-1255 801.261.5315 (Office) 801.261.1235 (Fax) [email protected] www.uda.org South Carolina Dental Association Mr. Phil Latham Executive Director 120 Stonemark Lane 126 For AGD Constituent Use Only Vermont State Dental Society Mr. Peter Taylor Executive Director 100 Dorset Street, Suite 18 South Burlington, VT 05403-6241 802.864.0115 (Office) 802.864.0116 (Fax) [email protected] www.vsds.org Wisconsin Dental Association Mr. Mark Paget Executive Director 6737 W. Washington St., Suite 2360 West Allis, WI 53214 414.276.4520 (Office) 414.276.8431 (Fax) [email protected] www.wda.org Virginia Dental Association Dr. Terry D. Dickinson Executive Director 7525 Staples Mill Road Richmond, VA 23228 804.261.1610 (Office) 804.261.1660 (Fax) [email protected] www.vadental.org Wyoming Dental Association Ms. Diane Bouzis 259 South Center Suite 201 Casper, WY 82601 307.237.1186 (Office) 307.237.1186 (Fax) [email protected] www.wyda.org Air Force Dental Corps Maj Katherine Morganti Bolling Air Force Base 110 Luke Avenue SW, Room 300 Washington, D.C. 20032 202.404.4119 (Office) [email protected] www.airforce.com Washington State Dental Association Mr. Stephen A. Hardymon Executive Director 126 NW Canal St. Seattle, WA 98107 206.448.1914 (Office) 206.443.9266 (Fax) [email protected] www.wsda.org Army Dental Corps Col Kay Malone Bldg 4011, MCCS-HE 1750 Greeley Road Fort Sam Houston, TX 78234-5075 210.295.9604 (Office) [email protected] www.goarmy.com/amedd/dental/index.jsp West Virginia Dental Association Mr. Richard D. Stevens Executive Director 2016 1/2 Kanawha Boulevard East Charleston, WV 25311 304.344.5246 (Office) 304.344.5316 (Fax) [email protected] www.wvdental.org Navy Dental Corps LCDR Wade Wallace 2300 E Street NW Washington, D.C. 20372-5300 901.874.9381 (Office) [email protected] www.navy.com/careers/officer/healthcare/de ntistry 127 For AGD Constituent Use Only Veterans Affairs Dr. Robert Frame Asst. Undersecretary for Health for Dentistry 810 Vermont Avenue, NW Washington, D.C. 20420-0001 202.273.8503 (Office) 202.273.9105 (Fax) www.vacareers.va.gov Department Of Defense Dr. Lawrence D. McKinley Tricare Management Activity Skyline 5, Suite 810 5111 Leesburg Pike Washington, D.C. 22041-3206 703.681.0064 (Office) 703.681.3681 (Fax) U.S. Public Health Service Dr. Chris Halliday Indian Health Service Division of Oral Health 801 Thompson Avenue, Ste. 300 Rockville, MD 20832 301.443.4320 (Office) 301.594.6610 (Fax) [email protected] www.dentist.ihs.gov www.defenselink.mil 128 For AGD Constituent Use Only State Departments of Insurance Listed below are the contact names, telephone numbers, and addresses for each State Department of Insurance: National Association of Insurance Commissioners (NAIC) Headquarters: 2301 McGee Street, Suite 800 Kansas City, MO 64108-2662 Office: 816.842.3600 Fax: 816.783.8175 Alabama Jim L. Ridling, Commissioner Alabama Department of Insurance 201 Monroe Street, Suite 502 Montgomery, AL 36104 Office: 334.269.3550 Fax: 334.241.4192 800.433.3966 (State Only) Alaska Linda Hall, Director Robert B. Atwood Building 550 West 7th Avenue, Suite 1560 Anchorage, AK 99501-3567 Office: 907.269.7900 Fax: 907.269.7910 800.467.8725 (State Only) Arizona Christina Urias, Director Arizona Department of Insurance 2910 North 44th Street, Suite 210 Phoenix, AZ 85018-7256 Office: 602.364.2499 Fax: 602.364.2505 Arkansas Jay Bradford, Commissioner Arkansas Department of Insurance 1200 West 3rd Street Little Rock, AR 72201-1904 Office: 501.371.2600 Fax: 501.371.2618 800.852.5494 (Consumers) 800.282.9134 (Toll-Free) 800.224.6330 (Seniors Only) California Steve Poizner, Commissioner California Department of Insurance 300 Capitol Mall, Suite 1700 Sacramento, CA 95814 Office: 916.492.3500 Fax: 916.445.6552 800.927.4357 (State Only) State of California Legal Division 45 Fremont Street, 23rd Floor San Francisco, CA 94105 Office: 415.538.4010 Fax: 415.904.5889 Consumer Services Division 300 South Spring Street, South Tower Los Angeles, CA 90013 Office: 213.897.8921 800.927.4357 (State Only) 129 For AGD Constituent Use Only Colorado Mary Morrison, Commissioner Colorado Division of Insurance 1560 Broadway, Suite 850 Denver, CO 80202 Office: 303.894.7499 Fax: 303.894.7455 800.930.3745 (State Only) Connecticut Thomas R. Sullivan, Commissioner Connecticut Department of Insurance P.O. Box 816 Hartford, CT 06142-0816 Office: 860.297.3800 Fax: 860.566.7410 800.203.3447 (State Only) 153 Market Street, 7th Floor Hartford, CT 06103 Delaware Karen Weldin Stewart, Commissioner Delaware Department of Insurance Rodney Building 841 Silver Lake Boulevard Dover, DE 19904 Office: 302.674.7310 Fax: 302.739.5280 800.282.8611 (State Only) District of Columbia Gennet Purcell, Esq., Acting Commissioner Department of Insurance, Securities & Banking Government of the District of Columbia 810 First Street, N.E., Suite 701 Washington, DC 20002 Florida Kevin McCarty, Commissioner Office of Insurance Regulation The Larson Building 200 East Gaines Street, Room 101A Tallahassee, FL 32399-0301 Office: 202.727.8000 Fax: 202.535.1196 Office: 850.413.5914 Fax: 850.488.3334 800.342.2762 (Helpline) Georgia John Oxendine, Commissioner Georgia Department of Insurance 2 Martin Luther King Jr. Drive West Tower, 704 Atlanta, GA 30334 Office: 404.656.2070 Fax: 404.657.8542 800.656.2298 (State Only) 130 For AGD Constituent Use Only Hawaii Gordon Ito, Commissioner Hawaii Insurance Division Department of Commerce & Consumer Affairs P.O. Box 3614 Honolulu, HI 96811-3614 Office: 808.586.2790 Fax: 808.586.2806 335 Merchant Street, Room 213 Honolulu, HI 96813 Idaho William Deal, Director Idaho Department of Insurance 700 West State Street, 3rd Floor Boise, ID 83720-0043 Office: 208.334.4250 Fax: 208.334.4398 800.721.3272 (State Only) Illinois Michael McRaith, Director of Insurance Illinois Department of Insurance 320 West Washington Street, 4th Floor Springfield, IL 62767-0001 Office: 217.785.4515 Fax: 217.782.5020 877.527.9431 (Toll-Free) 100 West Randolph Street, Suite 9-301 Chicago, IL 60601-3395 Office: 312.814.2420 Fax: 312.814.5416 Indiana Carol Cutter, Commissioner Indiana Department of Insurance 311 West Washington Street, Suite 300 Indianapolis, IN 46204-2787 Office: 317.232.2385 Fax: 317.232.5251 Iowa Susan Voss, Commissioner Iowa Insurance Division 330 East Maple Street Des Moines, IA 50319 Office: 515.281.5705 Fax: 515.281.3059 877.955.1212 (State Only) Kansas Sandy Praeger, Commissioner Kansas Insurance Department 420 S.W. 9th Street Topeka, KS 66612-1678 Office: 785.296.3071 Fax: 785.296.7805 800.432.2484 (State Only) 131 For AGD Constituent Use Only Kentucky Sharon P. Clark, Commissioner Kentucky Office of Insurance P.O. Box 517 Frankfort, KY 40602-0517 Office: 502.564.3630 Fax: 502.564.1453 800.595.6053 (State Only) 800.648.6056 (TTY) 215 West Main Street Frankfort, KY 40601 Louisiana James J. Donelon, Commissioner Louisiana Department of Insurance Attn: Chad Brown P.O. Box 94214 Baton Rouge, LA 70804-9214 Office: 225.342.5900 Fax: 225.342.8622 800.259.5300 (State Only) 800.259.5301 (State Only) 1702 North 3rd Street Baton Rouge, LA 70802 Maine Mila Kofman, Superintendent Maine Bureau of Insurance Department of Professional & Financial Regulations State House Station Augusta, ME 04333-0034 Office: 207.624.8475 Fax: 207.624.8599 800.300.5000 (State Only) 76 Northern Avenue Gardiner, ME 04345 Maryland Elizabeth Sammis, Commissioner Maryland Insurance Administration 200 St. Paul Place, Suite 2700 Baltimore, MD 21202-2272 Office: 410.468.2090 Fax: 410.468.2020 800.492.6116 (Toll Free) 800.846.4069 (Fraud) 800.735.2258 (TTY) Massachusetts Joseph G. Murphy, Commissioner Massachusetts Office of Consumer Affairs & Business Regulation Division of Insurance 1000 Washington St., 8th Floor Boston, MA 02118-2218 Office: 617.521.7794 Fax: 617.753.6830 617.521.7794 (Hotline) 132 For AGD Constituent Use Only Michigan Ken Ross, Commissioner State of Michigan Office of Financial & Insurance Services Attn: Office of the Commissioner P.O. Box 30220 Lansing, MI 48909 Office: 517.373.0220 Fax: 517.335.4978 877.999.6442 (Toll-Free) Ottawa Building, 4th Floor 611 West Ottawa Lansing, MI 48913 Minnesota Glenn Wilson, Commissioner Minnesota Department of Commerce 85 7th Place East, Suite 500 St. Paul, MN 55101-2198 Office: 651.296.4026 Fax: 651.282.2568 Mississippi Mike Chaney, Commissioner Mississippi Insurance Department P.O. Box 79 Jackson, MS 39205 Office: 601.359.3569 Fax: 601.359.2543 800.562.2957 (State Only) 1001 Woolfolk State Office Building 501 North West Street Jackson, MS 39201 Missouri John M. Huff, Director Missouri Department of Insurance 301 West High Street, Suite 530 Jefferson City, MO 65101 Office: 573.751.4126 Fax: 573.751.1165 800.726.7390 (State Only) Montana Monica J. Lindeen, Commissioner Montana Department of Insurance 840 Helena Avenue Helena, MT 59601 Office: 406.444.3497 Fax: 406.444.1980 800.332.6148 (State Only) Nebraska Ann M. Frohman, Director Nebraska Department of Insurance Terminal Building, Suite 400 941 O Street Lincoln, NE 68508 Office: 402.471.2201 Fax: 402.471.4610 877.564.7323 (State Only) 133 For AGD Constituent Use Only Nevada Brett J. Barratt, Commissioner Nevada Division of Insurance 788 Fairview Drive, Suite 300 Carson City, NV 89701-5753 Office: 775.687.4270 Fax: 775.687.3937 800.992.0900 (State Only) 888.872.3234 (Health Complaints-State Only) New Hampshire Roger A. Sevigny, Commissioner New Hampshire Insurance Department 21 South Fruit Street, Suite 14 Concord, NH 03301 Office: 603.271.2261 Fax: 603.271.1406 800.852.3416 (Toll-Free) New Jersey Thomas B. Considine, Commissioner New Jersey Department of Insurance 20 West State Street, PO Box 325 Trenton, NJ 08625 Office: 609.292.7272 Fax: 609.777.0508 800.446.7467 (Toll-Free) New Mexico John G. Franchine, Superintendent New Mexico Department of Insurance P.O. Drawer 1269 Santa Fe, NM 87504-1269 Office: 505.827.4601 Fax: 505.476.0326 800.427.4722 (State Only) PERA Building 1120 Paseo de Peralta Santa Fe, NM 87501 New York James J. Wrynn, Superintendent New York State Insurance Department 25 Beaver Street New York, NY 10004-2319 Office: 212.480.6400 Fax: 212.480.2310 800.342.3736 (Toll-Free) 888.372.8369 (Fraud) New York Department of Insurance One Commerce Plaza, Suite 1700 Albany, NY 12257 Office: 518.474.6600 Fax: 518.473.4139 North Carolina Wayne Goodwin, Commissioner North Carolina Department of Insurance 1201 Mail Service Center Raleigh, NC 27699-1201 Office: 919.733.3058 Fax; 919.733.6495 800.546.5664 (State Only) Dobbs Building 430 North Salisbury Street Raleigh, NC 27603 134 For AGD Constituent Use Only North Dakota Adam Hamm, Commissioner North Dakota Department of Insurance 600 East Boulevard Ave., 5th Floor Bismarck, ND 58505-0320 Office: 701.328.2440 Fax: 701.328.4880 800.247.0560 (State Only) Ohio Mary Jo Hudson, Director Ohio Department of Insurance 50 West Town Street Third Floor, Suite 300 Columbus, OH 43215-1067 Office: 614.644.2658 Fax: 614.644.3743 800.686.1526 (Toll-Free) 800.686.1527 (Fraud) 800.891.5318 (CE) 800.686.1578 (OHIIP) Oklahoma Kim Holland, Commissioner Oklahoma Department of Insurance Five Corporate Plaza 3625 NW 56th, Suite 100 Oklahoma City, OK 73107 Office: 405.521.2828 Fax: 405.521.6635 800.522.0071 (State Only) Oregon Teresa D. Miller, Insurance Administrator Oregon Insurance Division P.O. Box 14480 Salem, OR 97309-0405 Office: 503.947.7980 Fax: 503.378.4351 888.877.4894 (State Only) 350 Winter Street NE Salem, OR 97301-3883 Pennsylvania Joel Ario, Commissioner Pennsylvania Insurance Department Commonwealth of Pennsylvania 1326 Strawberry Square, 13th Floor Harrisburg, PA 17120 Office: 717.783.0442 Fax: 717.772.1969 877.881.6388 (Consumer) Puerto Rico Ramon Cruz Colon, Commissioner Office of the Commissioner of Insurance B5 Calle Tabonuco St. Suite 216 PMB 356 Guaynabo, PR 00968-3029 Office: 787.722.8686 Fax: 787.273.6082 135 For AGD Constituent Use Only Rhode Island Joseph Torti, III, Deputy Director and Superintendent of Insurance Rhode Island Department of Business Regulation Insurance Division 1511 Pontiac Avenue, Bldg 69-2 Cranston, RI 02920 South Carolina Scott H. Richardson, Director South Carolina Department of Insurance P.O. Box 100105 Columbia, SC 29202-3105 Office: 401.222.5466 Fax: 401.222.5475 Office: 803.737.6180 Fax: 803.737.6205 800.768.3467 (State Only) 300 Arbor Lake Drive, Suite 1200 Columbia, SC 29223 South Dakota Merle Scheiber, Director South Dakota Division of Insurance Department of Revenue & Regulation 445 East Capitol Avenue, 1st Floor Pierre, SD 57501-3185 Office: 605.773.3563 Fax: 605.773.5369 Tennessee Leslie Newman, Commissioner Tennessee Department of Commerce & Insurance Davy Crockett Tower, 5th Floor 500 James Robertson Parkway Nashville, TN 37243-0565 Texas Mike Geeslin, Commissioner Texas Department of Insurance P.O. Box 149104 Austin, TX 78714-9104 Office: 615.741.2218 Fax: 615.532.6934 800.342.4029 (State Only) Office: 512.463.6169 Fax: 512.475.2005 800.578.4677 (State Only) 333 Guadalupe Street Austin, TX 78701 Utah Neal T. Gooch, Commissioner Utah Department of Insurance 3110 State Office Building Salt Lake City, UT 84114-6901 Office: 801.538.3800 Fax: 801.538.3829 800.439.3805 (State Only) 136 For AGD Constituent Use Only Vermont Mike Bertrand, Commissioner Vermont Division of Insurance Department of Banking, Insurance & Securities 89 Main Street Montpelier, VT 05620-3101 Virginia Alfred W. Gross, Commissioner State Corporation Commission Bureau of Insurance Commonwealth of Virginia P.O. Box 1157 Richmond, VA 23218 Office: 802.828.3301 Fax: 802.828.3306 800.964.1784 (State Only) Office: 804.371.9741 800.552.7945 (State Only) 877.310.6560 (Ombudsman and Consumer Services— Out-of-State) Virginia Bureau of Insurance State Corporation Commission 1300 East Main Street Richmond, VA 23219 Virgin Islands Gregory R. Francis Lieutenant Governor/Commissioner #18 Kongens Gade Charlotte Amalie, St. Thomas, VI 00802-6487 Office: 340.774.7166 Fax: 340.774.9458 Division of Banking & Insurance 1131 King Street, Suite 101 Christiansted, St. Croix, VI 00820 Office: 340.773.6459 Fax: 340.719.3801 Washington Mike Kreidler, Commissioner Washington State Office of the Insurance Commissioner P.O. Box 40256 Olympia, WA 98504-0256 Washington State Office of Insurance Insurance 5000 Building 5000 Capitol Way Blvd., SE Tumwater, WA 98501 137 Office; 360.725.7000 Fax: 360.586.2018 800.562.6900 (State Only) For AGD Constituent Use Only West Virginia Jane L. Cline, Commissioner West Virginia Department of Insurance P.O. Box 50540 Charleston WV 25305-0540 Office: 304.558.3354 Fax: 304.558.4965 888.879.9842 (Consumer Service Division-State Only) State of West Virginia 1124 Smith Street Charleston, WV 25301 Wisconsin Sean Dilweg, Commissioner Office of the Commissioner of Insurance State of Wisconsin P.O. Box 7873 Madison, WI 53707-7873 Office: 608.266.3585 Fax: 608.266.9935 800.236.8517 (State Only) 125 South Webster Street Madison, WI 53703-3474 Wyoming Ken Vines, Commissioner Wyoming Department of Insurance 106 East 6th Avenue Cheyenne, WY 82002-0440 Office: 307.777.7401 Fax: 307.777.2446 800.438.5768 (State Only) American Samoa Aoomalo Manupo Turituri, Commissioner Office of the Governor American Samoa Government Pago Pago, American Samoa 96799 Office: 684.633.4116 Fax: 684.633.2269 Guam John P. Camacho, Banking and Insurance Commissioner Department of Revenue & Taxation Regulatory Division P.O. Box 23607 Barrigada, Guam 96921 Building 13-3, 1st Floor Mariner Avenue Tiyan, Barrigada, Guam 96913 138 Office: 671.635.1817 Fax: 671.472.2643 For AGD Constituent Use Only Mariana Islands Michael Ada, Commissioner Commonwealth of the N. Mariana Islands Department of Commerce Office of the Insurance Commissioner Caller Box 10007 CK Saipan, MP 96950 Office: 670.664.3064 *Source: Home page of the National Association of Insurance Commissioners (accessed August 30, 2010) 139 For AGD Constituent Use Only MedWatch: The Food and Drug Administration’s MedWatch program was formally launched in June 1993. It solicits reports from health professionals about serious and adverse events that occur through the use of medical devices, prescription and over-the-counter drugs and other FDA-regulated products. The agency defines an adverse event as “any undesirable experience associated with the use of a medical product in a patient” and considers an event to be serious when the outcome is: death, congenital anomaly, or requires intervention to prevent permanent impairment or damage. Reports to MedWatch are confidential, and health care providers are not required to present proof when reporting an adverse incident or problem product. The AGD has joined the ADA, American Medical Association, and more than 50 other organizations as an FDA MedWatch Partner. As a MedWatch Partner, we inform our members about this program and to motivate them to play a role in postmarket surveillance. As of February 1994, 65 percent of all MedWatch reports were about an adverse drug event, 20 percent regarded medical devices, 11 percent a drug quality problem, four percent were biologic and one percent related to food. One percent of all individuals reporting to MedWatch were dentists. You may request a form for reporting adverse events by either mail or fax to: MedWatch 5600 Fishers Lane, HFD-200 Rockville, MD 20857 800.332.1088 Fax: 800.332.0178 www.fda.gov/medwatch/report/hcp.htm Food and Drug Administration 5600 Fishers Lane Rockville, MD 20857-0001 888.463.6332 www.fda.gov 140 For AGD Constituent Use Only Federal Agency Contact Names and Addresses: Because of the active role that the AGD is taking in access to care issues, a constituent president may need to make contact with representatives of HHS agencies. To maintain open lines of communications, we must know how to contact our counterparts in other professional associations and government agencies. A list of the HHS agencies and their missions. Centers for Disease Control and Prevention—Division of Oral Health—The CDC is the federal agency with primary responsibility for community-based programs aimed at preventing oral disease and promoting oral health, and for applied research to enhance oral disease prevention. The DOH takes the lead for these activities through four main approaches: monitoring oral diseases, promoting effective prevention strategies, building capacity within state and local health infrastructures, and guiding infection control in dentistry. Centers for Medicare & Medicaid Services (CMS)—formerly the Health Care Financing Administration (HCFA)—administers the Medicare and Medicaid programs, which provide health care to America’s aged and indigent populations, about one in every four Americans, including nearly 18 million children and nursing home coverage for low-income elderly. The CMS also administers the new Children’s Health Insurance Program through approved state plans that cover more than 2.2 million children. Health Resources and Services Administration (HRSA) helps provide health resources for medically underserved populations. HRSA supports a nationwide network of 643 community and migrant health centers, and 144 primary care programs for the homeless and residents of public housing, serving 8.1 million Americans each year. HRSA also works to build the health care workforce and maintains the National Health Service Corps, oversees the nation’s organ transplantation system, works to decrease infant mortality and improve child health and provides services to people with AIDS through the Ryan White CARE Act programs. National Institutes of Health—National Institute of Dental and Craniofacial Research (NIH/NIDCR)—The mission of the National Institute of Dental and Craniofacial Research (NIDCR) is to the promote the general health of the American people by improving their oral, dental and craniofacial health. Through nurturing fundamental research and the development of researchers, the NIDCR aims to promote health, to prevent diseases and conditions, and to develop new diagnostics and therapeutics. Knowledge acquisition through science and effective and efficient science transfer are the means used to contribute to improved quality of health. Interprofessional Relations: As access to care issues emerge at the forefront, many organizations other than the AGD will be involved in alleviating lapses in patient care. Recent legislative actions are opening caries prevention modalities that once were the sole purview of dentistry. Some states are allowing compensation by Medicaid for fluoride varnishes placed by pediatricians. Other states are expanding the role of dental auxiliaries by loosening the supervision requirements by dentists. A partial listing of professional contacts follows: 141 For AGD Constituent Use Only The American Academy of Pediatrics (AAP)—The mission of the AAP is to attain optimal physical, mental, and social health and well being for all infants, children, adolescents, and young adults. To this purpose, the AAP and its members dedicate their efforts and resources. The American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village, IL 60007-1098 847.434.4000 American Academy of Pediatric Dentistry (AAPD)—The AAPD is dedicated to improving and maintaining the oral health of infants, children, adolescents, and persons with special health care needs. American Academy of Pediatric Dentistry 211 East Chicago Avenue, Suite 1700 Chicago, IL 60611-2637 312.337.2169 The American Dental Association (ADA)—The ADA is the professional association of dentists committed to the public’s oral health, ethics, science and professional advancement; leading a unified profession through initiatives in advocacy, education, research, and the development of standards. American Dental Association 211 East Chicago Avenue Chicago, IL 60611 312.440.2500 Emergency Preparedness: In light of the occurrences of September 11, 2001, dental organizations and individual dentists have become more interested in the field of emergency preparedness. With proper training, dentists can be valuable adjuncts in emergency medical care, mass casualty management, forensic identification of victims, or many other fields. Constituents can organize and offer emergency preparedness training sessions. Individual dentists can become involved in local and national efforts. Again, using the Internet, many valuable sources for information on emergency preparedness can be found by going to a web browser as above and typing “Emergency Preparedness.” Examples of some Web sites found are listed as follows: http://www.phe.gov/preparedness/pages/default.aspx - Home page of the U.S. Department of Health and Human Services, Office of Emergency Preparedness (OEP) http://www.fema.gov/ —Home page of the U.S. Federal Emergency Management Agency (FEMA) 142 For AGD Constituent Use Only http://www.bt.cdc.gov/ —CDC page for Public Health Emergency Preparedness and Response In addition, many state and local groups have Web sites to be explored. Involvement of constituents or individual members is limited only by comfort levels and depth of training. 143
