Constituent Dental Care/Practice Chairperson’s Resource Manual September 2010 Originally Published: August 1992 Revised: November 1994 Revised: February 1997



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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 broad-based 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


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 pre-estimate, 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



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



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)

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

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.

AGD CHECKLIST FOR RESOLVING PROBLEMS WITH

DENTAL PRODUCTS AND MATERIAL

 I Have you followed the manufacturer’s directions for using the product?


 Yes  No
 A. Were there any indications that there might be a problem with using this material? If yes, please specify what they were.
 Yes  No
 B. 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. C ommunicate 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 pre-authorization 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.
 V 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.
 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*


  • 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.

AGD CHECKLIST FOR RESOLVING PROBLEMS WITH

DENTAL EQUIPMENT

 I Have you followed the manufacturer’s recommended maintenance schedule?


 Yes  No
 A. Have there been previous indications that there might be a problem

with the equipment?


 Yes  No
 B. How old is the equipment? _____ Years _____ Months
Has it recently been moved or undergone any physical disturbance?
 Yes  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.
 II 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.

 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.

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

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 peer-review committee are available through your state dental association.



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:
Table of Contents

ADVOCACY POLICIES

2010-11

TABLE OF CONTENTS


Primary dental care provider, defined 88

Insurance, Malpractice 92

AGD Access to Care White Paper 112

Prevention 112



POLICIES

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