Managing Dental Claims - One Call Care Management

Published by the Public Risk Management Association
www.primacentral.org
february 2014
Managing
Dental Claims
By Laura Gorman, RN, VP Clinical Sales
One Call Care Dental + Doctor
February 2014 | Public Risk
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W
ork-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 challenging 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’ compensation, 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
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Public Risk | February 2014
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 claimant’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 cooperation 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.
www.primacentral .org
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
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.
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% Functionality
Teeth 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 Implants
In 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 consideration 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.
February 2014 | Public Risk
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Managing Dental Claims
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 complications). 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 Cases
Temporomandibular 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’ compensation 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.
Published in Public Risk, February 2014. Copyright 2014. All rights reserved.
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