the dentist’s guide
DESCRIPTION
Dental Benefit Plans. NYSDA. The Dentist’s Guide. Understanding Your Patients’ Dental Benefits. Table of Contents. Dental Benefits Benefit Plan Provisions Types of Plans Fraud and Abuse Claim Submission FAQ’s. Dental Benefits. What are dental benefits? - PowerPoint PPT PresentationTRANSCRIPT
The Dentist’s Guide
Understanding Your Patients’
Dental Benefits
DentalBenefit Plans
NYSDA
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Table of Contents
Dental Benefits
Plan Provisions
Types of Plans
Fraud and Abuse
Claim Submission
FAQ’s
• Dental Benefits
• Benefit Plan Provisions
• Types of Plans
• Fraud and Abuse
• Claim Submission
• FAQ’s
Table of Contents
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Table of Contents
Dental Benefits
Plan Provisions
Types of Plans
Fraud and Abuse
Claim Submission
FAQ’s
• What are dental benefits?
• Why employers offer dental benefits?
• Dental benefits and your practice
Dental Benefits
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
What are dental benefits?
Provisions in the contract
between an employer and
employee that helps cover
the cost for the employee to
maintain or improve their
oral health.
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Companies give dental benefits to
• Decrease employee absences
• Prevent poor work performance
• Maximize profit margin
• Aid employee recruitment & retention
Why Employers Offer Dental Benefits?
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Who has benefits?
• What are “benefit plan provisions?”
• How are “coordination of benefits”
determined?
• Is there an “assignment of benefits?”
• Are “co-payments” due?
Dental benefits and your practice
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Who has benefits?
• Patients must verify “eligibility”
• Verifying a patient’s coverage is a courtesy
• A patient may not be eligible for benefits
• Unless dentist is a “participating provider,”
eligibility cannot be guaranteed
• Documentation of eligibility includes
“effective date of coverage”
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Who has benefits?
• If applicable, the patient must
know the “expiration date”
• There may be a period of limited
coverage after the expiration date
called an “extension of benefits”
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
FAQ’s
Table of Contents
Dental Benefits
Plan Provisions
Types of Plans
Fraud and Abuse
Claim Submission
FAQ’s
• Parameters in the patient’s plan that affect their reimbursement*
• These parameters will help in determining the coordination of benefits, the assignment of benefits, and the amount of co-payment.
Benefit Plan Provisions
*These provisions should never influence the quality of care delivered to the patient.
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Benefit Plan Provisions
• Limitations of Coverage• LEAT or LEPAAT• Pre-Existing Conditions• Exclusionary Period• Proof of Loss• Coordination of Benefits• Non-duplication of Benefits• Maintenance of Benefits
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Limitations of Coverage
• Sometimes called “exceptions” or
“exclusions”
• Restrictive conditions in a dental
benefits contract affecting how an
individual or group is covered
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Limitations of Coverage
Examples:
• age restrictions – (ex.: sealants covered to age 12)
• time limitations – (ex.: children covered to age 21)
• waiting periods – (ex.: 3 months before coverage starts)
• benefit exclusions – (ex.: no orthodontics)
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Least Expensive Alternate Treatment
• LEAT, also called “the least expensive professionally acceptable treatment” (LEPAAT)
• Restricts benefit allowance to coverage for the least expensive method of treatment*
*Determination of benefits is independent of the final treatment decision made by the dentist and the patient.
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Pre-existing Conditions
• An oral health condition that existed before the patient was enrolled in the dental benefit program
• Benefit plans will only cover a loss incurred while the patient is covered
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Pre-existing ConditionsExample:
A patient missing a 1st molar
prior to coverage will not get
a benefit for a fixed bridge or
a removable partial denture
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Exclusionary Period
The period of time, defined by
the dental benefits contract, in
which a reimbursable
restoration or procedure is
functional (its life-span)
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Exclusionary PeriodExample:
If a replacement for a single
crown will only be reimbursed if
the original is greater than 5
years old then its exclusionary
period is 5 years
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Proof of Loss
• Valid documentation of the covered
patient’s treatment includes dates, costs,
records, and approved codes and forms.
• This information is needed to determine
the financial liability of the company
providing dental benefit plan
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Coordination of Benefits
• When a patient is covered by more
than one dental benefits plan
• The liability for each plan is
determined by the contract
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Coordination of Benefits
Coverage will be designated as
“primary” and “secondary” with
assigned liabilities, benefits for
specific procedures, and
reimbursements by the plan
administrators.
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Non-duplication of Benefits
By contract, many dental
plans will not give a benefit if
the plan is the patient’s
“secondary” coverage.
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Non-duplication of BenefitsExample:
• Patient will not receive 100%
reimbursement for procedure usually
reimbursed by either plan at 50%
• Patient will receive only the 50% from
the “primary” coverage
• “Secondary” plan will not pay benefit
because of non-duplication clause in
the contract.
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Maintenance of Benefits
• Assuming that the benefit of the
secondary coverage is higher
than the primary
• The secondary coverage will
reimburse the difference, if the
allowable has already been met
by the primary
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Maintenance of Benefits
• If the benefit of the primary
coverage is equal or higher
then the secondary coverage
pays nothing.
• This preserves or maintains
the benefit, at least to the level
of the secondary coverage.
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Table of Contents
Dental Benefits
Plan Provisions
Types of Plans
Fraud and Abuse
Claim Submission
FAQ’s
• Fee-for-Service
• Managed Care
• Discount / Referral
Types of Dental Benefit Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Dental Benefit Plans
Dental benefit plans generally
are divided into two categories:
– Fully insured
– Self-funded
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Dental Benefit Plans
Fully insured plans
– The financial risk is transferred to the
insurance company.
– The plan and the insurance company
are subject to state insurance laws
and regulations.
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Dental Benefit Plans
Self-funded plans
– The worker’s employer, union, or group
assumes the financial risk.
– Self-funded plans are regulated
primarily by U.S. Labor Department
under federal ERISA statutes
(Employee Retirement Income Security
Act).
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Traditional Fee-for-Service
• Direct Reimbursement
• Indemnity Plans
Fee-for-Service Dental Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Dentist provides service
• Dentist determines fee
• Patient pays for service
• No coverage. No limitations
• No exclusions. No third party
Traditional Fee-for-Service
Dentist PatientFinancial relationship
Medical-legal relationship
Traditional fee-for-service is not a dental plan, but is included in this presentation to provide us with the base line or null plan
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• DR is a self-funded dental benefits plan
• Employee pays for treatment from any
dentist
• Employee reimbursed for dollars spent
on treatment
Direct Reimbursement
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Reimbursement dictated by employer’s
plan design
• DR is ADA’s recommended form of 3rd
party reimbursement
• Coverage is limited to the money in the
patient’s DR account maintained by the
employer
Direct Reimbursement
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Go to the ADA’s website for more info
Direct Reimbursement
Dentist PatientFinancial relationship
Medical-legal relationship
Employer
Financial relationship
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Fully insured or self-insured plans
• Patients receive benefits regardless of
dentist they select
• Predetermined reimbursement for
specific services, regardless of dentist’s
actual charges
• Payments to enrollees or, with
authorization, to dentist directly
Indemnity Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Fully insured indemnity plan relationships
Indemnity Plans
Dentist PatientFinancial
Medical-legal
Financial (Reimbursement)
Insurance Co. EmployerContractual
Authorization
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Self-funded plan relationships
Indemnity Plans
Dentist PatientFinancial
Medical-legal
Financial (reimbursem
ent)
Employer / Union / or Group
Autho
rizat
ion
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Limit coverage by . . .
– Using a “deductible”
– Use of a “UCR schedule”
– Having a “schedule of allowance”
– Establishing an “annual maximum”
– Paying for the “least expensive
alternative treatment” (LEAT)
Indemnity Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Deductibles
– A per patient or per family charge
that is not reimbursed by the
dental plan at the initial use of the
plan for its calendar year
– Requires patients out-of-pocket
contribution to fee
Indemnity Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
The UCR Schedule
– UCR = “usual, customary, and
reasonable”
– Actually benefit company’s
proprietary basis for its
reimbursement allowance
– No defined relationship to any
dentist’s actual fees
Indemnity Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
The UCR Schedule
– Determined contractually between
3rd party and plan purchaser
– Provides reimbursement based on
percentile of UCR schedule
– “Co-payment” equals difference
between plan’s allowable benefit and
dentist’s actual fee
Indemnity Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Schedule of Allowance
– Lists covered services and shows
how much the plan will pay for each
service. The patient is responsible
for the difference, the “co-payment”
Indemnity Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Annual Maximum
– Maximum amount that insurance
plan will pay during a calendar year,
after the patient has met required
deductible
– Establishes a limit of liability, per
individual or family
Indemnity Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Indemnity Plans
LEAT clause
– Restricts benefit allowance to
coverage for the least expensive
method of treatment
– Independent of the final treatment
decision made by the dentist and the
patient
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Preferred or Participating Provider
Organizations (PPOs)
• Closed Panel PPOs
• Health Maintenance Organizations (HMO)
Managed Care Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Changes reimbursement
– Plan may reimburse dentist directly
– Patient may receive different reimbursement for
using “in-plan” or “out-of-network” dentist
Managed Care Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Managed Care Plans
• Designed to reduce health care costs
• Presume over-utilization of treatment services
• Transfer portion of financial liability from 3rd party and patient to doctor
• Reduce alleged “over-treatment” through financial disincentives to treat
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Managed Care Plans
• Requires dentist to contract with managed care company or other 3rd party payer, directly or through subcontractor
• Subcontracting groups include:– IPA (Independent Practice Association)
– PPO (Participating Provider Panels)
– LLC (Limited Liability Corporations)
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Dentist’s fees limited by contract
• Services are either covered, or non-
covered, or excluded from coverage
• Co-payment for non-covered or
excluded services may be
determined by contract, otherwise it
is traditional fee-for-service
Managed Care Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Fully insured managed care plan relationships
Managed Care Plans
Dentist Patient
Financial(non-covered)
Medical-legal
Insurance Co. EmployerContractual
Con
trac
tual
Fin
anci
al(a
ssig
nmen
t)
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Self-funded managed care relationships
Managed Care Plans
Dentist PatientFinancial
Medical-legal
Employer / Union / or Group
Contra
ctua
l
Finan
cial
(ass
ignm
ent)
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Dentist Contracts - PPO
• Participating Provider
Organizations [PPOs]
• Contract with dentists for fee
discounts and other concessions
• Contract with insurance companies
or benefit plans to offer discounted
benefits through panel dentists
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Dentist Contracts - PPO
• Most common form of managed
care in dentistry.
• Dentists negotiate individually
with PPO.
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Dentist Contracts - IPA
• Independent Practice Associations [IPA]
are a type of integrated group practice:
i.e., P.C., LLC
• Therefore IPA can enter into contracts
and negotiate fees on behalf of member
doctors
• Contracts with doctor-members
• Contracts only with HMOs to provide
dentists to treat HMO member-patients
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Dentist Contracts - LLC
• Limited Liability Corporations [LLC] are a type of integrated group practice: i.e., P.C.
• Therefore LLC can enter into contracts and negotiate fees on behalf of member doctors
• Contracts with doctor-members• Contracts with PPOs, HMOs, or benefit
companies directly to provide dentists to treat patients enrolled in discount dental plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Contract with dentists for discounted
fees and other concessions
• May be fully insured (insurance
company’s risk) or self-insured
(employer’s risk)
• Cost employers less than similar
indemnity plan
Preferred Provider Organizations
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Employees select a dentist from a
network.
• Employees may have to pay a co-
payment to the dentist, depending
on the service.
• Employees may have a point-of-
service option.
Preferred Provider Organizations
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Patients may receive some
benefit even when treated by an
“out-of-network” dentist.
• These patients get a significantly
reduced benefit.
• Patients pay the difference.
Point-of-Service Option
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Plan makes no reimbursement
when care is provided by non-
participating dentist
Closed Panel PPO
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Health Maintenance Organizations
• Contracts with individual dentists or groups (e.g. PPOs, IPAs, etc.)
• Benefit paid directly to providers, not patients
• Patients restricted or encouraged to see enrolled doctors to receive benefits
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Health Maintenance Organizations
• Transfers financial liability from third-party and/or patient to dentist
• Provides financial disincentives to treatment
• Popular with employers to reduce costs of health benefit package
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Reimbursement in Managed Care
• Fee-for-service
• Capitation
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Reimbursement in Managed Care
• Dentist contract with benefit plans or
group to accept specific fees from plan
• Fees may be discounted or eliminated
• Fees may be supplemented by fixed
patient co-payments
• Certain procedures may not be covered
• Dentist may forfeit ability to collect from
patients for certain treatment
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Reimbursement in Managed Care: Capitation
• Fixed monthly payment, per
patient or family, regardless of
services rendered
• Does not alter dentist’s fiduciary
responsibility to deliver
appropriate care
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Reimbursement in Managed Care: Capitation
Dentist’s income determined by:
– Negotiated capitation fees to dentist
– Size of enrolled panel assigned to
dentist
– Period of patient enrollment
– amount of treatment required by
patients in panel
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Discount / Referral plan relationships
Discount / Referral Dental Plans
Dentist PatientFinancial
Medical-legal
Third Party Marketers
Contra
ctua
l Financial
Contractual
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
• Third party marketers establish
schedule of fees
• Dentists contract with third-party
marketer to charge enrolled patients
based on established fee schedule
Discount / Referral Dental Plans
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Discount / Referral Dental Plans
• Patients enroll for a monthly charge
• Patients given list of contracted dentists
• Dentists discount their normal fees in
exchange for prospective referrals
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Discount / Referral Dental Plans
• Plan pays no actual benefits
• Patients pay all dental fees directly to dentist
• “Coverage” limited to fee discount in dentist’s
contract with marketer
• Non-listed services may be discounted as per
the contract, otherwise traditional fee-for-
service
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Table of Contents
Dental Benefits
Plan Provisions
Types of Plans
Fraud and Abuse
Claim Submission
FAQ’s
Examples of Fraud and Abuse
• Fee Forgiveness
• Coupons
• False Diagnosis
• Claims Padding
• Misrepresentation
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Examples of Fraud and Abuse
• Over-utilization
• Refund of fee to patient
• Upcoding
• Unbundling
• Billing for services not performed
• Other Fraudulent Schemes
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Actions Against Fraud and Abuse
• Restitution
• Civil litigation
• Criminal prosecution
• Professional Discipline
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Actions Against Fraud and Abuse
Professional Discipline:
– censure
– fines
– license probation
– license suspension
– license revocation
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Plan Regulation
• Plans are regulated by NYS
Insurance Laws
• Managed Care Plans (HMOs)
also regulated by NYS
Department of Health
• Self-funded plans are regulated
by US Department of Labor
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
How to Remediate Plan Violations
Violations of Managed Care Contracts
– Dentist may impose sanctions defined in
contract
– Dentist should consult with attorney
regarding contract violations
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
How to Remediate Plan Violations
Patient Contract Violations– Utilize appeal procedures– Complain to plan– Complain to plan purchaser (i.e.
employer)– Complain to NYS Insurance Dept.– Complain to US Dept. of Labor (self-
funded plans)– Consult with attorney
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Table of Contents
Dental Benefits
Plan Provisions
Types of Plans
Fraud and Abuse
Claim Submission
FAQ’s
Claim Submission
• Patient claim must specify type of
treatment received
• Date of service
• Name of treating dentist
• Dentist’s actual fee for patient’s treatment
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Claim Submission
• Dentists are not required to submit
patient claims
• Dentists under contract to a managed
care company may be contractually
obligated to submit claims for enrolled
patients
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Claim Submission
• Claim forms may allow patient to authorize
payer to send insured’s benefit directly to
the treating dentist
• This is purely a courtesy
• Authorization is NOT binding on the payer
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
When Submitting Claims . . .
Dentist must provide
– Accurate patient & provider information
– Accurate treatment information
• Date of treatment
• Types of treatment (CDT codes)
– Accurate fee information
– Timely claim submission
– Copies of records, when requested
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Substitute Benefits – CDT Code Changes
• Carrier extends alternate benefit when treatment service is not covered
• Payment made for less expensive alternative when service is not covered
• If service is covered, alternate treatment must be clinically appropriate for patient
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
3rd Party Dental Consultants
• Anyone may determine whether the policy covers services and patient is eligible for benefits
• When rendering decisions about quality or appropriateness of patient care– Must be licensed dentist in state where
patient is treated– Evaluating patient care and treatment
planning are facets of the practice of dentistry
– All state regulatory statutes and guidelines apply
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
When may 3rd party deny a claim? (Indemnity)
• Patient not covered by policy• Services not performed• Dentist did not charge patient for treatment• Services not covered• Services exceed policy limitations• Deductible not met• Patient benefits expended• Benefits received exceed plan allowable• Claim submitted beyond allowable time
limit
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
When will 3rd party payer deny a claim? (Managed Care)
• Dentist not under contract in “closed panel” plan
• Services excluded from coverage
• Services do not conform with plan definitions for “medical necessity” or “standard of care”
• Dentist’s maximum reimbursement exceeded
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
When must a 3rd party payer pay a claim?
• Patient enrolled in plan
• Treatment services covered
• Treatment within policy guidelines
• Patient eligible for benefits
• Deductible has not been met
• Annual maximum not reached
• Allowable reimbursement not met by second carrier
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
When can claim denials be appealed?
• Treatment is covered by policy• Patient eligible for benefits• Denial based on “standard of care”• Denial based on “least expensive
alternative treatment” clause – and alternative is not clinically appropriate for patient
• Denial based on “medical necessity”• Question about qualifications of
consultant
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
How can denials be appealed?
• 3rd party payer must provide internal review of disputed claim
• 3rd party payer must then provide objective external review
• Peer Review – under certain conditions• Patient may sue for contractual
violations• Possible 3rd party legal violations
– Complain to NYS Insurance Department– Complain to self-funded plan under ERISA
to US Labor Department
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Assignment of Benefits
• In true “assignment,” the doctor
becomes the benefit recipient;
e.g., No-Fault, Medicaid, some
managed care
• If payment is disputed, the doctor
engages in the dispute
• If no benefit is available, the doctor
loses recourse to seek payment from
the patient
NYSDA
Home / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’s
Frequently Asked Questions
• E-mail questions to NYSDental.org
• Responses will be e-mailed back
• New dental benefit info will be posted
on this site.