Look beyond what can be seen

Aug. 1, 2004
Much has been written about evidence-based dentistry and its associated parameters of care. Evidence-based parameters of care are nothing more than the scientific analysis of...

Tom Limoli Jr.

Much has been written about evidence-based dentistry and its associated parameters of care. Evidence-based parameters of care are nothing more than the scientific analysis of when you do what compared to how you do it if you actually do anything. To put it more simply, are we doing the appropriate treatment at the appropriate sequential time for the specific needs of an individual patient?

Parameters of care are very different, and many say we should not be confused or influenced by a benefit plans parameter of payment. This two-lane road moves in both directions — parameters of payment should not govern or direct parameters of care. Why?

A benefit plan's parameter of payment is guided primarily by the strength of the plan purchaser's almighty dollar. The more the purchaser pays for a plan, the richer the benefits available to the enrollees. High-dollar plans have high-dollar benefits. Conversely, low-dollar plans don't have a lot of covered benefits. One plan might provide a prophylaxis benefit every six months, while another provides reimbursement for the procedure one, two, or three times a benefit year.

So which plan actually costs more? Which plan has the overall greater benefit to the patient? Are higher preventive benefits reducing the need for more costly restorative, periodontal, and/or surgical therapies? These are the questions being asked by plan purchasers as well as dental researchers.

The patient's benefit plan may say, "Bitewing radiographs are reimbursed twice in a calendar year." To most dental offices this means, "Take bitewings every six months when the patient comes in for a prophy." Many offices that follow this thinking have been audited and asked to refund thousands of dollars previously reimbursed for these radiographs. Why? Because there was no documentation in the patient record indicating why the radiographs were ordered and/or what was found (diagnosed) by the doctor upon reviewing the prescribed films.

There is no liability for payment by a patient or insurance company for simply taking radiographs. There is liability for payment when the dentist puts on the hat of a radiologist and determines that there is — or is not — suspected pathology, and subsequently enters those findings in the patient record as a separate dated and signed report or as part of the treatment record for that day's visit. Read this carefully: If there is no documentation of radiographic findings, there is no liability for payment. In this situation, if payments have already been made, the office may be required to refund those monies. The need for radiographs is not determined by the benefit plan; the criteria are based solely on the clinical needs of the patient as documented in the patient's record.

The ADA Council on Scientific Affairs in JADA, Vol.132, February 2001, page 234, specified: "Routine use of radiography as a part of periodic examinations (evaluations) of all patients is an inappropriate practice. Because each patient is different from the next, radiographic examination should be individualized. The nature and extent of the diagnosis required for patient care constitute the only rational basis for determining the need, type and frequency of radiographic examination."

The panoramic film is often considered to be a superior diagnostic tool by general dentists and specialists. Health-care professionals consider the jaws, associated components, their function, and related pathology to be entirely within the realm of the dental profession. Given the magnitude of this responsibility, the first step to a thorough diagnosis might well begin with a "global" radiographic interpretation of all related anatomical landmarks. The scope of interpretation through many individual films simply cannot match the global aspect of the panoramic film, nor the simplicity of orienting the patient to understanding where we are viewing and what we are identifying.

So how does all this relate to your office bank deposit? Should it be legislated that all radiographs be reimbursed by all plans whenever they are deemed necessary and appropriate by the treating dentist? What entity will determine appropriate care? What science will be used? Should frequency and benefit limits ever be placed, considered, or enforced?

The patient must acknowledge and be accountable to you for the total cost of care prior to considering the dollar value of any insurance benefits. Yes, the total fee! If not, evidence-based parameters of care will become the benefit plan's parameter of payment. Then again, some might think that this could be a good thing.

Tom Limoli Jr. is the president of Atlanta Dental Consultants and the editor of Dental Insurance Today, a bimonthly publication that addresses third-party reimbursement in the dental office. He also is the author of Dental Insurance and Reimbursement Coding and Claim Submission. He can be contacted by phone at (404) 252-7808. Visit his Web site at www.LIMOLI.com.

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