Dental benefits information.
Linda J. Thornton
, DDS, MS, FACP
Director, Graduate Prosthodontics, Temple University School of Dentistry, Philadelphia, PA, USA.
More than 152 million people have dental benefits in the US. The four major categories of benefit plans include fee - forservice (43%), preferred/exclusive provider (PPO/EPO) (31%), dental health maintenance organizations (DHMO) (18%), and referral plans (8%).1 In the last 5 years, only dental plans with benefits that were primarily restricted to providers participating within the network (networkbased) have continued to demonstrate an increase in growth. Because these benefit plans are competitively priced with low “out - ofpocket” expenses, this trend is expected to continue.
Dental insurance is based on a contract between the employer and insurance company. Employers pay a large portion of the cost for health care either directly or through insurance premiums. The selection of the lowest fee schedules is value - based. Value is a combined function of
- benefit coverage,
- quality of the plan,
- employee satisfaction with the plan, and
- access to benefits.
All of these factors are related to the cost of the plan. Although maximum dental coverage plans are available, the premiums associated with these dental plans have adversely affected their selection. Sixty - five percent of employers who added a managed dental care program in the 1990s cited cost as the primary reason. Increased benefits were a secondary reason.
In the early 1970s, the amount of dental coverage was approximately $1,000 per year. Assuming a 6% rate of inflation every year, today’s benefits should be $4,549 annually. Unfortunately, it has increased to only $1,200 –$1,500. With the average cost for the surgical and prosthetic phases of implant therapy estimated at approximately $1,500– $2000 per implant, the lack of a long - term track record and low serviceability previously associated with dental implants prompted insurance companies to exclude any level of implant coverage.The Mechanics of Insurance Reimbursement
Fee schedules are generally used to pay dental claims. They are determined by charging patterns or relative - value units, which are calculated from a database of provider fees as cited on claims. The McCarran - Furgeson Act allows insurance carriers to compete amongst each other and share information to develop fee schedules and allowables. The Sherman Anti - Trust Act of 1890, however, prevents dentists from restraining such collusion.
Most insurance companies, namely Aetna, Blue Cross/Blue Shield, and Prudential, use the UCR (usual, customary, and reasonable) Payment Program to determine fee schedules for routine dental procedures. These are defined as follows:
- Usual - The typical or most common fee charged by the dentist.
- Customary (determined by the dentist) - Takes into consideration extenuating conditions, ie, increased chair time. Even though it is not the usual fee, it is still customary for that particular situation. Both unusual and customary are defined by the American Dental Association.
- Reasonable (determined by the insurance companies) - Fees from claims, submitted by both general practitioners and specialists, are classified according to three - digit zip code areas.
The 90th percentile is typically used as the reasonable threshold. Therefore, 90% of all fees submitted are equal to or fall below the level determined to be a reasonable fee. ENHANCING EXISTING COVERAGE.
Recognizing the cost involved with implants, many insurance companies have developed additional dental plans to include implant bene fits. Aetna/U.S. Healthcare, for example, has several dental plans that cover as much as 50% of the cost for implants up to the annual maximum. If the selected dental plan covers replacement of missing teeth, the submitted claim is referred to the utilization review area where the clinical elements of the claim are evaluated. In most cases, a percentage of the cost will be covered by the insurance plan. However, when this occurs it may “wipe out” the member’s dental benefits for the entire year.
Although implant coverage is considered to be minimal at best, there are clinical situations that could reduce the out - of - pocket cost to the patient. Implant therapy consists of surgical and restorative components. Depending on the plan, ie, its criteria for coverage and the individual case, the surgical component and associated surgical procedures (ridge augmentation, sinus lift, vestibuloplasty, etc. may be covered under the patient’s medical plan). POLICY REVISIONS.
As the marketplace evolves and adapts within a financially constricted environment, insurance companies will continue to place greater emphasis on quality. Approval of dental claims based solely on the “gold standard” philosophy, ie, “it works—patients get better,” will no longer serve as an acceptable policy. Gold standards change over time and vary greatly from patient to patient and region to region. Therefore, insurance companies are upgrading their current implant policy to make it more in line with “the state of the science.”
Working in consort with consultants from academia and private practice, the focus will be directed toward reviewing clinical outcomes and evidenced - based research. Policies will be reassessed to determine the
- indications and contraindications that should be in place,
- clinical documents required from the dentist, and
- demonstrated value of any associated procedures necessary for implant placement (ridge augmentation, sinus lift, vestibuloplasty, etc.).
In an effort to provide an efficient yet effective management of the limited funds available, insurance companies will be focusing on alternative treatment modalities. Although implant therapy is an accepted treatment modality, it may not be the only treatment considered for benefit coverage. The less costly alternatives such as partial and/or complete dentures could be viewed as professionally accepted treatment options. In these instances, insurance companies are not dictating treatment but rather determining benefits based on what is least costly and professionally acceptable. FINANCING PROGRAMS.
As the trend toward implant dentistry and other elective procedures increases, the need to make these services affordable must be considered. Greater than 85% of dentists in private practice and academic institutions in the United States accept payment by major credit cards. Unfortunately, high interest rates with an average available cash limit of $300 do not make them a viable option for treatment costs of several thousand dollars or more.
Patients and providers can benefit from the several types of designated healthcare credit cards, ie, CareCredit, MedCash, and Pulse Card, to provide them with a separate line of credit from $5,000 to $10,000. Patients benefit by having a convenient alternative payment method with no annual fees and low interest rates. Providers benefit by receiving payment at the time of treatment with a reduction in billing and collections.REFERENCES.
- The Dental Benefits Report - National Association of Dental Plans 2000. Dallas, TX: National Association of Dental Plans; 2000:5.
- The Dental Benefits Industry and Your Future Dental Practice (Dental School Presentation Outline). Provided by National Association of Dental Plans, Dallas, TX; revised June 2000:1–13.
- DePorter DA. The future of dental benefits. J Am Coll Dent. 1997; Fall:10– 11.
- Jacobs PH. The Economics of Health and Medical Care. Rockville, MD: Aspen Publishers; 1987:264–266.