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
Electronic claims are certainly very popular in dentistry.
Is there an opportunity for that to become the
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
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
A lot of dentists complain that the annual limit
on plans has not changed for 40 years. What are
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.