Reimbursement Barriers to Dental Screening

by | Published on Aug 26, 2015 | Specialty Billing

Dental Screening
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According to healthcare experts, around 70 to 80 percent of bills for preventive or diagnostic dental care services such as preventive screenings, fluoride treatments and others can be covered with traditional fee-for-service plans or preferred-provider plans. While there may be co-payments and deductibles, dental care settings can claim their reimbursement from relevant carriers with correct dental coding. However, a 2014 qualitative study by a group of American researchers discuss the several barriers that exist as regards the reimbursement for oral rapid HIV testing and other preventive screenings.

What Are the Major Obstacles?

As per the study, if some preventive screenings such as that for oral cancer got widespread insurer support and reimbursement, others such as population-based HIV screening encountered several barriers to reimbursement. The main barriers are:

  • Compared to standard medical coverage, there is a low annual maximum benefit for dental insurance. So when the available funds are spent on preventive screening, that amount would be deducted from the maximum dental benefit and it would limit the amount available for expensive procedures such as root canal therapy and bridge prosthesis. This financial hurdle plays a crucial role in patients’ decision whether they need a preventive screening or not.
  • Dental plans are subject to market demands and preferences of the employer. The plan will provide an additional service when the employers value it highly or when it becomes a standard industry practice. This will lead to uncertain reimbursement.
  • Even if a plan offers both medical and dental coverage, it will segregate medical and dental reimbursement systems, staff, procedures, records and reimbursement codes. Concerns exist regarding handling test results and how a referral would be made back to a primary care provider (PCP) if a patient received a positive test result on screening. Co-ordination and integration may be difficult between medical and dental offices, dental plans and dentists. Communication of results back to the PCP may not be very smooth.
  • There was also the issue about dentists not obtaining appropriate training and practice guidelines to ensure proper health screening and effective communication of a positive test result with proper treatment referral.
  • Patients’ reluctance to certain screenings that are not traditionally identified with the dentist’s professional role (for example, HIV screening) is another major concern. Certain insurance companies express their discomfort for HIV screening owing to social stigma and complex treatment referral process.

Effective Solutions

Some effective solutions put forth to overcome the above mentioned barriers are as follows.

  • The Affordable Care Act (ACA) provides a useful model to address uncertain reimbursement issues. As per this act, public and private payers are required to provide first-dollar coverage of clinical preventive services, that have obtained either A or B rating from the US Preventive Services Task Force. This ensures proper reimbursement for necessary preventive screening during dental care. However, dentists should perform insurance verification process thoroughly and confirm that patients are eligible for coverage under ACA before providing the service.
  • The segregation of records of oral health from other health services is a major obstacle to proper integration of dental services with other medical care. The National Network for Oral Health Access and the National Association of Community Health Centers promote the electronic health record option that integrates medical and dental records and systems (electronic medical/dental record) to accomplish this. With this option, the computerized record of patients’ health details will reside in a single healthcare organization and at the same time ensure more efficient provision of integrated healthcare services and communication. If it is integrated with the software that tracks dental billing, the dental care provider can maintain an effective, centralized billing and collection system and improve overall management of reimbursement.
  • Pilot programs that provide formal training for dentists to perform screening, delivering results and referring patients for follow-up will enable the proliferation of formalized practice guidelines that impact both providers and insurance plans. Giving proper education to patients about the benefits of screening is also very important.

Rajeev Rajagopal

Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.

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