Carol Tekavec, RDH
The latest installment in the fight between the Minnesota Dental As soc iation and Delta of Minn esota, the state's largest dental insurer, resulted in the passage of the landmark "Dental Benefits Disclosure Act," effective August 1, 2000. Delta Dental of Minnesota, under its PRIME program, had been using its utilization-review information to rank its participating dentists on a profile system of practice patterns. Dentists who fit a "good" profile were being compensated at a higher fee rate than dentists who deviated from the profile. Some "deviant" dentists even had their fees frozen in 1999!
An even larger problem was Delta making reimbursement and provider-retention decisions based on secret compilations of utilization data that it was defining as evidence of "good practices." According to Delta, dentists were scored on "their orientation to provide economic value in treatment approaches ... in relation to Delta's statistical model, utilizing current research and clinical standards." Dentists outside of the "statistical model" still could be a part of the Delta network, but had their reimbursement levels frozen. What was worse, Delta would not explain or provide information about what criteria was actually being used to rank the dentists.
Utilization data and review have long been popular insurance methods to measure the numbers and types of services provided by dentists participating in a dental plan. However, a model that uses "current research and clinical standards," secretly compiled and interpreted by a dental plan to distinguish "good" dentists from "not good" dentists, goes beyond what the Minnesota dentists felt was acceptable.
The new Minnesota law requires all insurance carriers in the state to reveal the methods they use to profile utilization, as well as to show individual dentists the actual criteria used for reimbursement decisions.
Information that must be made available upon request includes:
- A description of the utilization profile methods used, so that 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 a dentist 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 of how he or she might qualify or retain qualification for a particular plan.
Utilization data by itself has historically not been used to identify "best practices." In fact, the idea of "best practices" usually is thought to be the combination of a dentist's clinical expertise with recent scientific studies.
If utilization information is used as a "best practices" criteria, then an insurance company can define a best-practice profile as one including many standard prophys and very few root-planings. That practice profile would cost the carrier less than a profile showing more root-planings. The company might find that profile more economically valuable and define that as "best." While this might be thought of as a business right of the entity paying the bills, other conclusions can be drawn when the information is also secret (such as the dentist not being the "best" because of providing inferior treatment).
In the case of the Minnesota Dental Association vs. Delta of Minnesota, this round has gone to the dentists. Passage of the "Dental Benefits Disclosure Act" compels insurance companies to reveal many of their informational and statistical methods. Actual carrier compliance with the Act remains to be seen. It is likely that legal confrontations will occur.
Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonetosuccess.com.