Utilization and standard of care

1) "The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals.

Carol Tekavec, RDH

Most dental offices are familiar with the terms utilization and standard of care.

Utilization is defined by the ADA Glossary of Dental Benefit Terminology as:

1) "The extent to which the members of a covered group use a program over a stated period of time; specifically measured as a percentage determined by dividing the number of covered individuals who submitted one or more claims by the total number of covered individuals.

2) "An expression of the number and types of services used by the members of a covered group over a specified period of time."

Standard of care typically is understood as an accepted level of treatment by qualified professionals under normal conditions. These terms impact any dental practice that works with a patient`s indemnity insurance, dental HMO, or PPO plan.

While utilization and standard of care typically have not been associated within the minds of practicing dentists, they have long been connected in the computers of third-party carriers.

Most dental insurance indemnity plans - as well as dental HMOs and PPOs - carefully monitor the number of visits and types of services their subscribers receive during a given period of time. The information is assembled from submitted claim forms in the case of indemnity plans, and from "encounter forms" in the case of HMOs and PPOs. (Encounter forms usually are listings of patient names, treatment dates, and procedure codes a dentist must submit monthly for tracking by the HMO and/or PPO he or she contracts with).

An analysis of the data usually is performed on a per-month and on a year-to-date basis. Subscriber copayments and/or balance billing also are monitored. The results of the analysis are compared with other data, such as the industry-determined "UCR" fee for each geographic area and the number of procedures performed by each dentist compared to other dentists. The primary purpose of the evaluation is to assess treatment variations against what the carrier has established as the "norm."

Dentists who participate with a dental plan may be scrutinized heavily if their practice patterns vary from what typically is seen in their city. For example, a general dentist in Denver, Colo., may perform molar endo at a rate twice that of his/her hometown colleagues. The computer will note the discrepancy and may flag the dentist as an "outlier" - someone who practices outside a standardized "norm" of practice pattern.

However, the Denver dentist may perform more endo for many reasons. Other dentists in the area may know that he/she has completed extra education in endodontics, and thus refer their own patients. Satisfied patients may refer their friends who have similar problems. The dentist`s patient base may be older with a greater chance of endo needed, or he/she simply may be able to talk more patients into avoiding extractions.

The insurance company`s utilization-review computer program is not able to track subjective reasons such as these. Instead, a dentist who performs procedures outside of the expected geographic percentage simply is seen as an over-user of procedures or an abuser of the system. Such dentists cost dental plans money.

Delta Dental Plan of Minnesota recently used its utilization-review information in a unique way. It is eliminating capitation and discount fees from new dental contracts, and, in their place, is establishing a ranking system to determine who is paid what fee. By using years of claim data, Delta has ranked its participating dentists on a profile system of practice patterns. Dentists who have closely adapted to a standard practice/procedure profile are considered "good performers." Delta will be raising the fee compensation of these dentists. Dentists who do not fall within the standard norm may continue to participate with Delta, but will have their fees frozen at 1998 levels.

Delta claims that it is using practice-pattern data to define a desirable standard of care. Dentists who are having their fees frozen claim that the data has nothing to do with quality of care, but simply is a method of using utilization numbers to force out dentist "outliers."

Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.

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