Managing Dental Claims

february 2014Published by the Public risk management association www.primacentral.org

February 2014 | Public Risk 1

by laura Gorman, rn, VP Clinical salesOne Call Care Dental + Doctor

Work-related accidents—such as slips, falls, car accidents, being hit by moving objects or even incidents of workplace violence—can result in dental trauma and even tooth loss. although dental injuries are less common than other types of workers’

compensation claims, they can present significant challenges, complications and costs.

Public agencies, as well as their claims and risk management staff (referred to as payers throughout this article), have come to realize that dental claims require specialized clinical knowledge and oversight. In this article, we outline strategies that can help to ensure appropriate, cost-effective dental claims management:

• referrals tO Quality Dentists & Dental sPeCialists

Workers’ compensation provider networks have not focused on recruiting dentists. As a result, identifying a dentist who has experience with the workers’ compensation claims process and is willing to accept such cases can be chal-lenging and time-consuming. Even when claims adjusters and nurse case managers find a dentist, they have no way of knowing if the dental provider has a quality track record. Using unqualified dentists can result in poor control of the claim, particularly in regards to costs and outcome.

Today, specialized dental networks and dental referral management companies have scheduling centers, which ensure a high level of service and efficient appointment coordination. Care coordinators typically schedule an oral exam within 24 hours of receiving a request and can identify a dental provider conveniently located to the claimant’s home or work.

These organizations utilize a comprehensive provider credentialing process, which ensures that injured workers are sent to quality dental providers and specialists (such as a periodontist, endodontist, or oral maxillofacial surgeon). The care coordination team also helps dentists to fulfill workers’ compensation requirements, such as completing mandatory forms and ensuring appropriate authorization and billing procedures are followed.

• an injury-sPeCifiC treatment Plan

General dentistry involves treating the patient’s whole mouth to ensure good oral health, but in workers’ compen-sation, a payer may only be responsible for conditions related to the work-related injury.

For example, a worker may have fallen and chipped a tooth; a general dentist might send a treatment plan for four

cavities, periodontal disease, and gingivitis to the payer. To avoid this, a specialized clinical management team must work with the dentist to develop a treatment plan specific to the work-related injury.

The dentist will observe the overall condition of the claim-ant’s mouth and send documented notes to the clinical team, which usually consists of nurses, dental hygienists, dentists, and other dental specialists. This team performs a clinical review of the file and works with the dentist to identify whether special dental conditions exist.

In one case, a woman in her late 40s was hit by a valve. The accident knocked out her two front teeth. In coop-eration with the dentist, the clinical team determined that the claimant had a history of periodontal disease and possibly inadequate bone to support implants, which would have been a good restorative option, but the poor condition of the claimant’s mouth made it a high-risk procedure.

The dentist’s recommended treatment plan, involving a bridge, was sent to the adjuster for authorization. A clinical management team should have in-depth knowledge of dental procedures and pricing to help the adjuster understand dental services and set appropriate reserves. In this particular case, the payer saved $5,065 through effective treatment and discounted dental rates. Since the clinical management team also facilitated prompt care, it prevented further infection and minimized lost time, resulting in an additional $3,000 savings.

• HanDlinG Dental Claim COmPlexity

For proper clinical management, an organization must have access to dental expertise that can assist with—and when necessary explain—various types and levels of claims complexity.

Often to the detriment of cases, adjusters and nurses will rely on their personal experience with dentistry. For example, an adjuster may have had a sister who chipped her tooth and simply required a filling. However, an injured worker with a chipped tooth may need a root canal and crown.

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managing Dental Claims

When people don’t

take care of their

mouths, bones

break down and

gum disease occurs.

initially, adjusters and

nurses may think

their organization

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poor dental hygiene.

However, the

claimant’s teeth

were fully functional

before the injury,

and now to restore

functionality, more

extensive treatment

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to first address the

tooth decay and

gum disease.

This adjuster may feel the dentist is trying to over-treat, while the dentist feels that given the claimant’s dental condition, he’s outlined a standard treatment protocol. Dentists are often inexperienced in workers’ compensation, and therefore, may not adequately explain to the adjuster the treatment requirements in relation to the injury. However, a clinical management team interacts with workers’ compensation professionals on a daily basis, so dental clinicians have communication strategies to explain why certain approaches to treatment are required.

In this case, the clinical dental expert explained that teeth are like porcelain. If there’s a small chip, it may be fixed with a filling, but if it extends into the structure of the tooth, as it did with this claimant, then it would require more extensive restoration, such as a root canal and crown.

• restOrinG 100% funCtiOnalityTeeth perform three vital functions: they enable people to eat, speak, and support the structure of their face. When an injury occurs that compromises these capabilities, the payer is responsible and must restore functionality.

When there is significant decay or another compromising condition, the way in which a dentist restores functionality differs greatly than if a claimant has healthy teeth, bone structure, and gums. It is sometimes difficult for adjusters and nurses to understand why different treatment options are necessary. When this occurs, analogies to more common cases, such as knee injuries, can be helpful.

Let’s say a male security guard in his late 50s falls at work and injures his knee. Over the years, he hasn’t taken good care of himself. He’s overweight, hypertensive, and smokes. He goes to physical therapy, but doesn’t

get better. An orthopedic surgeon recommends knee surgery to restore his ability to walk. Adjusters and nurses readily understand that a knee replacement is necessary, even though deterioration already exists caused by the breakdown of the bone supporting the joint and hindering the claimant’s ability to walk. As such, they will likely authorize the surgery.

In the dental world, the situation is similar. When people don’t take care of their mouths, bones break down and gum disease occurs. Initially, adjusters and nurses may think their organization isn’t responsible for the claimant’s poor dental hygiene. However, the claimant’s teeth were fully functional before the injury, and now to restore functionality, more extensive treatment may be necessary to first address the tooth decay and gum disease.

A dentist may determine that the loss of functionality is 40 percent related to pre-existing conditions and 60 percent related to the injury. However, you cannot fix 60 percent of a claimant’s mouth and restore 100 percent functionality, and similarly you cannot replace 60 percent of a knee to restore 100 percent of the claimant’s ability to walk. Ultimately, you need to perform 100 percent restoration to achieve 100 percent functionality. With this type of analogy, claim handlers better understand the need for more extensive dental treatment.

• aDVisinG On Dental imPlantsIn recent years, the use of implants as a restorative option to replace a single tooth or set of teeth has become more widespread—and with good reason. With careful consid-eration of any risk factors or complications, implants have been highly successful and long lasting. With proper care, implants can last a lifetime and generally have a success rate of 95 to 98 percent.

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The main drawback is expense and time. An implant can cost several thousand dollars per tooth, and the entire process can take up to 12 months or longer (without complica-tions). However, the benefits are proving to far outweigh the disadvantages, especially given the alternatives. Bridges and dentures often need to be replaced and refitted over time, and when the tooth is lost, bone atrophy can occur.

A clinical management team can help to identify if claimants may have potential risk factors or complications with this procedure, and identify specialists who have the right expertise to successfully complete this procedure, such as specialized training, appropriate years of experience, and a high five-year and 10-year success rate.

• manaGinG tmj CasesTemporomandibular Joint (TMJ) disorder may be caused by a punch to the jaw or due to post-traumatic stress that triggers grinding of the teeth. It is one of the most problematic and potentially costly dental-related claims. For example, a typical TMJ injury can call for joint replacement, fat grafting and injections, which can exceed $100,000. Recovery is challenging because patients cannot rest the jaw; personal stress or a bump can impede recovery and require treatment to begin over again. The complexity of treatment and ease of re-injury often result in injuries that become long-tail claims. The clinical management team will help to coordinate care and ensure the proper specialist is retained at the right time.

• minimizinG future risk & exPOsure

The clinical team can also help to avoid future risk and exposure. In one case, a male in his late 50s was hit in the mouth and damaged his two front teeth. There were two treatment options. The first was a root canal and crown on each of the two front teeth. Since the patient’s teeth were in poor condition, the second option was to remove all the upper teeth and provide an upper denture.

The clinical team worked with the dentist and determined that the first option was the best, most appropriate treatment plan. It was 100 percent related to the injury, and the patient had adequate bone structure to support the crowns. This option would also avoid the risk and exposure of future denture replacements, relines, and adjustments that could eventually be required as the patient aged, a potential savings of $7,500 in future costs.

Throughout the clinical management process, organizations are also able to place a keen emphasis on injured workers, getting claimants the prompt service and quality dental care they need, so they are not only pleased with the outcome, but also benefit from restored functionality and early return to work. When claimants are satisfied, payers experience less contention and a lower overall rate of litigation over claims.

Dental manaGement best PraCtiCes In summary, dental claims management must employ in-depth clinical expertise to help contain claims costs—first, through a carefully developed injury-related treatment plan; second, through a prompt and efficient referral and care management process, which ensures immediate treatment, restoration of functionality and return to work; and third, by providing clinical oversight that minimizes future risk and exposure. Excellence in the referral and scheduling process must include thorough documentation, appropriate billing, and compliance with workers’ compen-sation requirements.

Finally, providing claims adjusters and nurse case managers with continuing education (CE) courses and webinars, so they have a basic understanding of dental terminology and restoration techniques. With this type of training, claims professionals can better discuss dental injuries and treatment options, and have a realistic expectation regarding dental claims duration and cost.

Laura Gorman is vice president of clinical sales at One Call Care Dental + Doctor.

managing Dental Claims

Published in Public Risk, February 2014. Copyright 2014. All rights reserved.This file is for web posting and email distribution; may not be used for commercial reprints.

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