Inside United Concordia by Thomas Giacobbi, DDS, FAGD, Editorial Director, Dentaltown Magazine

by Thomas Giacobbi, DDS, FAGD,
Editorial Director, Dentaltown Magazine


Insurance today. It mystifies even the most brilliant among us. Dentaltown Magazine Editorial Director Dr. Tom Giacobbi recently had the chance to pick the brain of Dr. James Bramson, Chief Dental Officer at United Concordia, a national dental insurer, for a deeper look inside dental insurance. Bramson provided interesting insight.

Electronic claims are certainly very popular in dentistry. Is there an opportunity for that to become the standard?
Bramson: Well certainly, what we’re seeing, is the insurance industry supports a lot of efforts to improve and support electronic claims submissions. There are many good reasons for that. The first one is that, typically, they’re just a lot more accurate. When people have to fill those out, they can’t leave out fields of informtion and things like that, which on our end would turn into a suspended claim. We see pretty high rates of electronic claim submissions these days. In our business it’s well over 75 percent. We see that continuing to trend upward. Once you get to where threequarters of the market is already submitting that way, there’s sort of the last and few holdouts that aren’t doing it.

Do you see a point in the future where amalgam restorations would no longer be covered?
Bramson: We cover amalgams; we cover composites. It’s mostly up to the purchaser. Most of the time they decide what they will cover—whether they want to have both of those claims of services covered and at what levels they want them covered. We still see that those are pretty serviceable restorations, and I would tell you by our claims that there’s an awful lot of amalgams that are still done. And when you look at claims—utilizations over time—the restorations are wonderful restorations from a longevity standpoint. Probably longer than what we see with composites.

Based on the data you see, how would you compare the longevity of an amalgam versus a composite?
Bramson: Sometimes we have a lot larger database on one or the other, but typically we would see a serviceable amalgam probably lasting somewhere between 25-50 percent longer than a composite… I don’t want to comment on a year basis. The best way I can comment on them is proportionally we see them last longer.

What percentage of claims are fraudulent?
Bramson: The sort of literature out there that you will read would probably peg it somewhere between three and 10 percent.

Has that become better or worse over time?
Bramson: Let me finish with the three and 10 before we go to better or worse. I think the 10, frankly, is high. I don’t believe it’s that high; I think it’s probably more in the three to five percent range. That’s kind of consistent with what we see. Is that getting higher? I think it’s probably trending up a little bit, yes. We have some pretty sophisticated technology that we have in place now, that was put in over the last couple of years that looks at claims differently, instead of just kind of looking at it on its face, one claim at a time. Generally when we start to see those, we’ll ask for some records to review, or we’ll talk to the doctor about any special circumstances in their case that may or may not be lending to some of those kinds of things.

I would also say the fact that the trend seems to be going up is reflective that we have better tools in finding it now. We need those tools so that we can protect patients from inappropriate and unnecessary care. When you sell a piece of dental business to a group, there’s an expectation on the part of the group purchaser that one of the things they’re doing by paying our services is knowing that we are actually monitoring these kinds of things for them. If we don’t do that well for them, and the fraud and the abuse is allowed to go unchecked, it’s actually their claims cost that they’re paying directly. So they have a vested interest in making sure we have good, robust systems and methodologies by which we look for these kinds of things.

Should there be better or more frequent examinations to potentially detect oral cancer in patients?
Bramson: What’s always interesting to me is that when I talk to individuals who have some kind of oral cancer complaint or grievance, I always ask, “Did your doctor do an oral cancer screening?” No, they didn’t do that. Did they look around in your mouth, and pull your tongue out, any of that? Oh yeah, they did that. There is this huge gap between what a dentist is doing normally and regularly in the course of their ongoing examination, that for some reason they’re not conveying to their patients what they just did. I don’t think it’s limited to oral cancer.

Lots of dentists are out there looking at periodontal disease, and probing and not telling their patients exactly what they’re doing. You can’t really fault the patient for not knowing what their doctor is doing when the doctors are not doing a real good job of summarizing either during the examination or at the end of the examination what they just did. I think that’s sorely missing and would go a long way in approving the ability of people to understand. Now, does that mean that every dentist is actually doing the screening for oral cancer? I doubt that. That is something they should be doing, just like they should be doing examinations for periodontal disease. It’s part of what being a professional is all about. It’s part of their duty to look for other kinds of diseases. It’s easy to do.

Why don’t we see coverage for dental implants as widespread as we see coverage for three-unit bridges?
Bramson: It’s probably more widespread than what most dentists believe. Implants are part of a fair number of insurance plans. Sometimes it’s included in the initial benefit in some way.

And we are talking about the surgical placement as well as the restoration of implants?
Bramson: A lot of times, companies purchase it as an add-on and wrap it around their existing policy. Those are usually large companies and we have a lot of those. There’s a lot of implant coverage being done that way. We also quite routinely apply the alternate benefits provision when an office has coverage for prosthetics. They apply the alternate benefits provision to the extent they can that would cover it. From our standpoint, we’re sort of saying, there’s coverage there to deal with that missing tooth, and we understand the state-of-the-art is not necessarily a three-unit bridge.

Has there been an impact in dentistry due to the Affordable Care Act?
Bramson: It is required in the sense that pediatric coverage is part of the essential benefits. I think it’s still very early to tell whether or not companies are going to do that (remove dental benefits from company insurance plans to reduce costs). We’re part of the Affordable Care Act in a lot of different ways. As a company, we’re embedded on exchanges with medical carriers in some cases, we’re off-exchange embedded, we’re stand alone, on or off. So we have lots of different kinds of products and plans out there, and what I think we’re seeing is that the purchasers are probably looking more at standalone plans right now, because a lot of the medical carriers in their initial plans to participate in the ACA found it easier to just deal with their medical issues, get their medical fillings done, and get up and on the exchange that way. And they were comfortable having a certified plan where the patient said, “I get my dental someplace else.” I think the bigger difference, however, is the actual decision is left up to the individual, and so you’ve got a person having to know what they’re buying. I think that changes the tenor. Where before, you had someone buying it for you, like someone in human resources. You have to become a more educated consumer.

A lot of dentists complain that the annual limit on plans has not changed for 40 years. What are your thoughts?
Bramson: That bunch of dentists probably needs to take a look at some of the newer plans. Let me give you an example: In one of our plans, there is a ten thousand dollar maximum. A lot of our contractual businesses with various clients, we have maximums of $2,500, $3,500. I’ve heard that argument that it hasn’t changed in decades. It has, and it’s a rapidly changing market.

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