Aggressive utilization review

If a dentist's practice patterns vary from what is considered 'typical,' computer software will flag him or her as an 'outlier.'

If a dentist's practice patterns vary from what is considered 'typical,' computer software will flag him or her as an 'outlier.'

by Carol Tekavec, RDH

Since a series of my columns appeared on the topics of adverse utilization review and practice profiling, I have received dozens of calls concerning the problems that dentists are facing. It seems to be a nationwide issue. This article will explore details concerning utilization, practice profiling, ranking, and adverse selection in an effort to help dentists and staff understand what is happening and how it all got started.

In the ADA Glossary of Dental Benefit Terminology, utilization review is defined as "a system that examines the distribution of treatment procedures, based on claims information ... In order to be reasonably reliable, the application of such claims analyses of specific dentists should include data on type of practice, dentist's experience, socioeconomic characteristics, and geographic location."

Utilization management is defined as "a set of techniques used by or on behalf of purchasers of health-care benefits to manage the cost of health care, prior to its provision, by influencing patient care decision-making through case-by-case assessments of the appropriateness of care based on accepted dental practices."

Utilization-review information has long been used by insurance carriers to determine what types of services — and the frequency of those services — that network dentists are providing. Utilization data traditionally has been employed to assess treatment variations against what the carrier has established as a "norm." (The "norm" does not necessarily take into consideration the ADA recommendations of analyses of "type of practice, dentist's experience, and socioeconomic characteristics.") If a dentist's practice patterns vary from what is considered "typical," computer software will flag him or her as an "outlier." Outliers are considered to be overusers of procedures. Carriers don't want outliers in their networks.

Despite the fact that most carriers have been using utilization data for years, a high-profile battle has been ongoing in the state of Minnesota regarding the use of utilization-review information, gathered by Delta Dental, for use in deciding who will participate in Delta's plans. Delta of Minnesota, under its PRIME program, has been using its utilization-review information to rate participating dentists on a profile system of practice patterns. Dentists who fit a "good" profile are compensated at a higher fee rate than dentists who deviate from the profile. ("Deviant" dentists had their fees frozen in 1999, and some even had their fees reduced in 2000.)

How did the dentists become "deviant?" It turns out that these dentists showed up outside the accepted curve on Delta's formats of utilization data according to "their orientation to provide economic value in treatment approaches ... in relation to Delta's statistical model, utilizing current research and clinical standards." When the "deviant dentists" asked for the data that showed them to be outside of the "model" — and, in fact, for an explanation of the "model" itself — they were told that the information was a proprietary trade secret. The dentists were not allowed to know what it was in the "model" that rendered them deviant, nor were they told exactly why their reimbursement levels were frozen or reduced.

In response to this situation, and others like it with other carriers, the "Dental Benefits Disclosure Act" was passed in August 2000 by the Minnesota state legislature. This law provides many requirements for insurance carriers regarding what information must be revealed to dentists who work with dental plans. Here is the information that must be made available to dentists:

  • A description of the utilization profile methods used, so dentists can understand how they are affected
  • A list of codes that are included in the profiles
  • A dentist's personal utilization data within each code, so that he or she can verify the information
  • A dentist's individual score according to the standards of the profile method used
  • An explanation of how a dentist compares with others to inform the dentist about how he or she might qualify or retain qualification for a particular plan

Delta of Minnesota is complying with the new law. Since August 2000, network dentists who requested an explanation of their utilization data and fee status received an individualized report. The report is confidential and described as being copyrighted under trade- secret and unfair-competition laws. In fact, each page of the individualized report states that the information is protected and that unauthorized disclosure is prohibited. In other words, Delta considers the information contained in the reports so secret that no dentist is allowed to discuss his or her data with any other person. Even so, Delta of Minnesota's CEO and president, Michael Walsh, categorizes Delta's approach to dental-benefit administration as being above board and straightforward.

Also, according to recent Delta of Minnesota information, only 228 dentists out of over 2,500 eligible participants have requested their individual reports since the passage of the Disclosure Act. Only two of the 228 have written responses saying that they could not understand their data. These two dentists' questions were said to have been handled by senior Delta corporate officers.

Despite this Delta assertion, I have received numerous calls from dentists since my February 2001 column — which featured information about Delta of Minnesota and its utilization and ranking system. The callers have told me that they could not understand their reports. Many said that the reports "made no sense."

With or without reports, the Disclosure Act does not change the fact that the entity that controls the money controls the situation. If employers do not wish to or cannot provide adequate benefits for their employees, they do not purchase adequate plans. Plans that are designed to cut costs will end up cutting procedures. It is simple arithmetic. So, whether they understand why or not, dentists who do not provide procedures according to "their orientation to provide economic value to treatment approaches" will not fare well in the Delta system. Other carriers also are facing the same employer demands for benefits at greatly reduced costs. "Economic value" takes precedence every time.

'Best practice' and 'economic value'
When utilization data is used as a "best practice" criteria to determine "economic value" to treatment approaches, then an insurance company might define a "best practice" profile as one that provides for the least expensive treatment. It might define "best practice" as doing standard prophys and few root-planings. It might define "economic value" as periodic examinations only once every year or two years, rather than twice a year. In fact, economic value can mean "more bang for the buck" or simply "less treatment than ever," depending on who is defining "value."

When utilization data is combined with certain types of "evidence," ultraconservative approaches to treatment can be promoted even further. For example, in the April 2001 issue of the Journal of the American Dental Association, an article on the "Efficacy of Subantimicrobial Dosing With Doxycycline" states that doxycycline provides a limited improvement of periodontal status when used with root-planing.

Because this article appeared in JADA and is of a conservative nature, it likely will be used from now on by many carriers to support decreasing the already very limited benefit coverage for subantimicrobials. Dentists who often use and submit claims for subantimicrobials (ADA Code D9630) may find themselves in a database that highlights them as overutilizers of the procedure and not as providers of "appropriate, cost-effective" treatment. If any other codes on claims attract interest, these dentists may find themselves subject to further adverse utilization review. Therein lies the problem. "Evidence" and statistics tell only part of the story.

Many dentists are unhappy with the processes of utilization review, practice-pattern review, and ranking, but find themselves in a predicament as to what to do about it. Dentists looking at the situation from the outside might advise unhappy colleagues simply to quit Delta and all other plans and go "insurance-less." In fact, it is reported that many PRIME dentists have already left the system.

Even so, it is just not that simple in some cases. Many dentists talk about dropping involvement in insurance plans; however, the truth of the matter is that most patients rely on insurance to help pay for dental treatment. For many patients, no insurance means no dental care. Despite how much a patient might wish to stay with a certain dentist, economics can be harsh. It is possible for a dentist to become a "nonparticipating" (non-network) provider with Delta while still continuing to accept Delta traditional indemnity insurance. This eliminates submitting fees or being ranked. However, patients are required to pay a larger portion of the total bill than under participating-provider, traditional indemnity plans. They must pay an even larger portion than under participating provider PPO or PRIME Delta plans. As a result, many patients will be inclined to leave.

What about dentists who are "disenrolled" or unilaterally dropped from plans due to adverse utilization review? It is unfortunate that many dentists who drop out or who are forced out of highly popular plans may find themselves without a sustainable practice. Due to economics and an underlying distrust of a dentist who has been dropped, many patients will choose other network dentists. Their rationale often is that the insurance carrier must be looking out for them, since much of the literature they receive from the carrier reinforces this belief. Other network dentists who see the problems facing "drop-out" dentists may become fearful of leaving a network even if they want to. An atmosphere of fear and distrust can become the norm.

On the medical side, the situation is similar. Many health plans are using utilization review and physician practice patterns to terminate physicians who are perceived as providing "too many" of certain types of services.

In 1999, a physician who had been a network provider for a health plan in Ohio was allegedly terminated for being an "overutilizer of medical resources at twice what the health plan thought it should be." After being dropped from the plan, the physician was allegedly forced to sell his practice due to lack of patients. The physician is suing the plan, and the outcome of this lawsuit still is pending.

You owe us money
While issues with utilization review can result in fee reductions for participating providers, they also can end up forcing dentists to pay back money that has been "billed and paid incorrectly." If a plan collects utilization information that indicates a dentist is performing more of a certain procedure than others in the same area, the insurer can demand repayment. The rationale typically stated by the insurer is that the dentist has billed the procedures incorrectly. Detailed records are the only defense.

If the dentist's contract provides for a records audit, the plan may send representatives into the practice to look through patient records to see if billing procedures match progress notes. If records are unclear on diagnoses, codes, and progress notes, the dentist typically has no recourse. Most plans have appeals processes, but without documenting records or the time and money to go through the process, many dentists simply pay the plan the money it says they owe.

What can you do?
Your state organization and groups such as the ADA Council on Dental Benefit Programs, the Academy of General Dentistry Dental Care Council, and the American Academy of Periodontology Third Party Manager should be contacted when problems occur with utilization review. They may have input to help you, or, at the very least, they may be able to add your complaint to a list.

Use up-to-date, CDT-3, 2000 procedure codes. Carriers that have not converted to the new codes yet may still be using CDT-2 or CDT-1 codes ... or they may even have their own codes for certain procedures. If you already know that the carrier uses a certain code for a procedure you have performed, it is permissible to use that code. If in doubt, always use the CDT-3 code.

Keep in mind that many carriers are on the alert for certain "problem" codes that they consider to be routinely overutilized, such as sealants billed as restorations. (Be aware that the CDT-3 has changed the D1351 sealant-code description to include mechanically prepared enamel surfaces.)

Let your patients know in advance that they may expect negative Explanation of Benefits (EOB) forms from their insurance carriers. If none arrive, so much the better. Explain that the insurance/dentist and insurance/patient relationships are often adversarial and that negative issues come up often. Let patients know that you are on their side. That means you need to keep the lines of communication open!


Document... document... document!

Although it seems obvious and is already a part of quality, comprehensive dental care, detailed documentation in the patient record is your single best defense for treatment and/or utilization issues. The expense in time needed for good recordkeeping is well worth it because it fulfills both your patient's perception of your professionalism and provides you with personal protection.

Be relentless in making sure that records (whether paper or computer) are clear and that they include all of the information pertaining to patient treatment. At a minimum, your records should include these items:

  • A detailed medical-history form with space for updating it regularly
  • An initial data-collection and treatment-recommendations form that details existing conditions, pathology, and a treatment plan for each tooth
  • A comprehensive periodontal-exam form that can be easily updated
  • A detailed schedule of treatment showing what will be done at each appointment
  • Appropriate informed-consent forms signed by the patient
  • Meticulous progress notes detailing each appointment
  • Diagnostic-quality radiographs
  • A written treatment estimate and financial agreement

It also is helpful to have a patient financial and personal information form and photos of problematic conditions, such as cracked teeth, undermined cusps, and fractures.

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