Whose evidence?

A lot of attention is being focused on the problems created by using "evidence" to determine the extent of an insurance plan's obligation to reimburse patients for covered services.

By Carol Tekavec, RDH

A lot of attention is being focused on the problems created by using "evidence" to determine the extent of an insurance plan's obligation to reimburse patients for covered services. Basing treatment on scientific research constitutes the primary premise behind "evidence-based dentistry." However, problems crop up when deciding which research to use.

For example, in the September 2000 issue of the Journal of the American Dental Association (JADA), an article appeared challenging the validity of a longstanding dental principle - the advisability of replacing missing posterior teeth. According to the article, a study lasting 6.9 years of 111 middle-aged patients with untreated, bounded edentulous spaces resulted in few adverse outcomes. These patients did not seen to suffer from tooth-shifting, loss of bone support, tooth extrusion, or other undesirable results. In other words, the study concluded that a patient who presents with a single-tooth, posterior-bounded edentulous space may not need immediate treatment to maintain arch stability. (A key factor to these findings might have been the fact that the sample consisted of primarily middle-aged subjects, not younger persons with less dense bone).

Because the article appeared in JADA, it probably will become a respected source of information and evidence on the topic of replacing missing teeth from now on.

At the ADA 2000 annual session, the following question was asked during a seminar on evidence-based dentistry: "Among the preventive therapies available, which one should you use to treat an enamel lesion?" A majority of the audience (60 percent) chose remineralization by reducing bacterial counts, reducing carbohydrates, and using fluoride. However, 40 percent of the audience disagreed. Was that 40 percent "wrong" because they were in the minority? Would the majority opinion always hold, or would there be circumstances favoring a different decision? Is there always only one "right" answer?

Where evidence is concerned, it is very likely that any studies coming out on the side of reducing the use of dental interventions and treatments will be used by insurers to limit payment for care. It also is very likely that evidence on the side of increasing interventions or treatment will be more popular with dentists.

It is a good idea to begin now to plan how your office will handle evidence-based, insurance payment denials for your patients. Rather than letting the issue run over your office like a speeding train, decide how you will help your patients and yourself get out of the way.

Some ideas: If you haven't already started using written and detailed treatment estimates that are presented prior to beginning treatment, start doing so now. Patients are more likely to be financially responsible for a higher percentage of their bills in the future. When finances are not addressed, patients can become angry and upset. Treatment must not be dictated by insurance benefits, so we must help our patients receive the care they need when we function as their advocates.

Patients want their insurance plans to pay the maximum possible. Most patients need dental staff to help them navigate the insurance maze. When viewed dispassionately, an insurance payment can be seen for what it is - an alternate method of helping patients pay for what they need - no different than a health credit card or a finance package from a bank. From the patient's point of view, insurance reimbursement has the added advantage of not having to be repaid. Helping patients with insurance does not have to mean payment parameters will determine treatment.

Keep in mind that you and your office set the tone for how insurance is viewed by your patients. When seen as just another form of monetary help, it can be welcomed, even if the benefit is not large!

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.

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