Dental Claims Control - keep smiling

Dental Claim Reduction Strategies

Frequency Limitation

There is no scientific evidence to support semi-annual dental examinations for everyone.
Early detection of disease is prudent but only for those at high risk.
The traditional 6 month frequency limitation is giving way to 9 and 12 month limitations.

Treatment

Most dental care consists of treating symptoms rather than the disease. Twenty percent of the population have elevated levels of bacteria that cause caries (cavities) and periodontitis (gum disease). Knowell Therapeutic Technologies Inc. and Oralife Care Management contend that by reducing the level of bacteria in those individuals you will be providing better dental care and reduce costs.

Fluoride

Employers should analyze the risk their employees have of getting cavities and base their decision to included or exclude topical fluoride treatments on the cost effectiveness of this preventive therapy.

Many studies have linked the dramatic decline in the rate of tooth decay in developed countries with the widespread use of fluoride in various forms, such as water fluoridation, fluoridated toothpaste, fluoride supplements, rinses, topical fluoride and other products. In fact, overall fluoride ingestion has increased to such an extent that there is concern over dental florosis (white spots on teeth).

Oral Hygiene Instruction

Many plan sponsors restrict or do not coverage oral hygiene instruction to limit claims abuse.

Periodontal Scaling

Some plan sponsors believe it to be reasonable for employees to contribute toward the cost of dental neglect.

Consider limiting the reimbursement level of dental scaling to 50%. This will require employees to scrutinize claims by being directly responsible for part of the cost. This should eliminate claims for services not rendered and involve employees in the treatment plan.

Alternately, consider limiting the number of units to 4-8 per year or at least requiring a documented diagnosis and treatment plan for claims in excess of 4 units per year. This may limit some claims abuse but still leaves 1 hour of scaling with no questions asked.

Another approach is to restrict coverage to services provided by a periodontal specialist. Removing the service from the general practitioner may be inconvenient and cost more per unit of scaling but it eliminates the conflict between the diagnoses and revenue generating treatment.

Scaling represented such a small portion of dental claims it never got much attention until claims began increasing at a rate of 30-60% per annum. It is difficult to believe that the increase in periodontal claims is due to solely to an increase in periodontal disease.

Amalgam Bonding

New developments in dental technology often need to be proven effective in the long term before covered by benefit plans.

Based on initial studies, amalgam bonding may be able to bring the strength of a tooth back to its original state in certain situations. However, the additional cost of bonding can significantly increase the cost of the amalgam. Many benefit plans only cover the cost to that of the corresponding non-bonded amalgam.

Wisdom Teeth Extraction

Employers may consider limiting reimbursement for impacted wisdom teeth (third molars) to situations of pain or medical necessity.

Over 90% of teenagers, whose parents have insurance, have their wisdom teeth removed even though less than 10% of wisdom teeth need removing. A study in the International Journal of Technology Assessments in Health Care recommends removing only those wisdom teeth that remain impacted and become pathologically involved.

Aesthetic

Some plans only cover anaesthetic when required for restorative procedures and restrict coverage for conscious sedation.

Replacement of Fillings

Some Plans only cover replacement fillings if they are at least five years old. This was in response to the practice of replacing amalgam fillings in the eighties.

Missing Tooth Provision

Most major restorative plans have a missing tooth provision which act as a pre-existing condition exclusion. It will only cover the cost of new bridges or dentures if at least one of the teeth involved were extracted while covered by the plan.

Fee Schedules

Most dental plans limit reimbursement to the general practitioner's fee schedule of the employee's province of residence or denturist for denture services.

This may be reconsidered if confidence erodes in the association's commitment to stability of fees. Current discussions surrounding the elimination of recall packages and blending of scaling and periodontal scaling could have a major impact on dental plans. The benefit industry may look within to set fees rather than rely on dental associations.

Some plans use specialist's fee schedules when the service is performed by a specialist. The prices are an average of 20% higher for specialists.

As dental hygienists organize we may see dental hygiene clinics provide access to dental treatment.

Capitation

Canadian employers have resisted the promise of cost savings through paying a fixed price for dental services regardless of the amount of service an employee requires. Freedom of choice in selecting a health care provider and preserving the doctor patient relationship is paramount.