Dental Benefits and Practice Management: A Guide for Successful Practices

Dental Benefits and Practice Management: A Guide for Successful Practices is a practical tool that helps you manage your office in tune with the realities of modern dental practice.

The early focus of the text is on dental insurance and payments. Chapters are devoted to the history of dental benefits and current benefit products; what the procedure codes are and how they are used; processing guidelines and denied and disapproved claim appeals; and streamlined processing, including pre–determination, coordination of benefits, and more. This segues into the second half of the text, which discusses ways to keep your practice patient–centered and out of legal trouble. Topics addressed are office processes and patient communication, risk management, recordkeeping and compliance, avoiding fraud and abuse, and the ethics of dental practice. Also explained are considerations for quality of care and how the Patient Protection and Affordable Care Act impacts dental benefits and access to dental care. The text concludes with strategies for dentists and organizations to become competitive in the new normal for dental care delivery. Appendices include sample forms, appeal and narrative sample, and a guide to risk management.

Chapter 1 Why Dental Benefits?
Michael Okuji

Introduction 2

The Coming of Health Insurance 3

Private Health Insurance 7

Moral Hazard 8

Indemnity insurance 10

Benefit service plan 11

Direct service plan 13

Direct reimbursement 14

Health Insurance The Blues 15

Federal Health Benefits 17

Dental Benefits 20

Dental Service Company 21

What is Dental Insurance? 22

Indemnity insurance 23

Dental benefit plan 23

Preferred Provider Organization 24

Health Maintenance Organization 25

Direct service plan 26

Direct reimbursement plan 27

Discount plan 28

Administrative Services Only 28

Bundled payment 29

Accountable Care Organization 30

Antitrust 31

Conclusion 32

Chapter 2 Dental Benefits get it done
Michael Okuji

Introduction 2

Dental Benefits 3

Plan design 6

Participating Provider Agreement 7

Credentialing 8

Medicare Opt–In Opt–Out 9

Fees 11

ADA Dental Claim Form (American Dental Association) 11

Dental claim field changes (2012) 13

Dental claim new fields 15

NPI (National Provider Identification) 17

TIN (Tax Identification Number) 18

Narrative attachment 18

EOB (Explanation of Benefits) 21

CDT Code 22

CDT Code Use 23

Categories of service 27

Exclusion and Limitation 29

Limitation 30

Frequency limitation 30

Narrative for exclusion, limitation, frequency 31

Electronic Claim Submission 32

Clearinghouse 32

Electronic attachment 33

Code Maintenance Committee 33

Non–Dentist Provider 35

Diagnosis Code 37

ICD–10 38

Conclusion 40

Chapter 3 Dental Benefits get it right
Michael Okuji

Introduction 2

Get–it–right 3

Participating Provider Agreement 3

Fees 4

Utilization 5

Utilization review 5

Prospective utilization review 6

Quality assurance audit 7

Appeal and dispute resolution 9

Appeal preparation 10

Termination 11

Summary 12

Dentist and Dental Plan Design 13

Dental Plan Contract 14

Dental Claim Process 15

Benefit eligibility 15

Evidence of coverage 17

Coordination of benefit 17

Non–duplication of benefit 18

Unbundled procedure 19

Balance billing 19

Non–covered service 20

Up–code 21

Deny and Disallow 21

Appeal a claim determination 22

Electronic Services 23

Eligibility 23

Pre–determination 24

Claim submission 25

Electronic funds transfer 25

Claim Filing Tips 26

Desktop Procedures 38

Conclusion.39

Chapter 4 Patient–Centered Practice
David Okuji

Introduction 2

Key to Transform the Health Care System 4

Transformation: Impact on Dentistry 8

Transformation: Evidence in Healthcare and Dentistry 11

Two tier financing 12

Two tier delivery system 13

Accountability 14

Electronic Health Record 15

Population health outcomes 16

Integration of medicine and dentistry 17

Population health outcome 18

Evidence based care 20

Mid–level provider 21

Group practice model 22

Oral Health Care Delivery Model 23

Organizational structure 24

Organizational Structure: Opportunity 27

Integrated medical and dental practice 27

Networked and integrated medical/dental practice 28

Stand–alone networked large group dental practice 29

A Networked solo practice 30

Patient Centered Care: Competitive Advantage 31

Conclusion 36

Chapter 5 Streamline the Practice
Michael Okuji, Dennis Lewis

Introduction 2

Private Practice 4

Systems and operation 4

Electronic eligibility 5

Pre–determination 6

Claim submission 8

Electronic claim submission 8

Electronic direct deposit 9

Electronic dental record 10

Access to the dental record 13

Diagnostic code 15

Airline Analytics 16

Sarrell Dental Center 18

Call center 19

Administration 20

Workforce 20

Community 21

Medical dental integration 21

Sarrell Dental Center team 22

Quality 23

Social Determinant of Health 25

Patient support system case management 26

Disease management 28

Generational determinant of health 29

Conclusion 30

Chapter 6 Patient Protection and Affordable Care Act
David Okuji, Michael Okuji

Introduction 2

ACA quality 3

Healthcare Insurance Marketplace 4

Public exchange 4

Private exchange 5

Affordable Care Act 6

Title I. Quality, affordable healthcare for all Americans 7

Title II. Role of public programs 7

Title III. Improve quality and efficiency of health care 7

Title IV. Prevention of chronic disease and improve population health 8

Title V. Health care workforce 8

Title VI. Transparency and program integrity 9

Title VII. Improve access to innovative medical therapies 9

Title VIII. Community living assistance service and support 9

Title IX. Revenue offset provision 10

Title X. Strengthen quality, affordable healthcare 10

Key Provisions 10

ACA Essential Health Benefits 12

Medicaid Expansion 13

ACA Funding 13

Drivers of Health Care Reform 14

ACA Quality and Outcome 15

ACA Themes 16

Actuarial Value 18

ACA Dental Benefit 19

Impact on Dentistry 20

Cost of Care 22

ACA Implication for Dentists 23

Pediatric specialist extenders 24

Society s expectations 26

Conclusion 27

Chapter 7 Ethics and Ethical Behavior
Gary Herman

Introduction 2

What is a Profession? 3

Ethical vs. legal 4

Ethics and professionalism 5

Ethics of quality of care 6

Perceptions of ethics and professionalism 7

Situational Ethics 9

Responsibility to the patient 9

Responsibility to improve health 11

Responsibility to family 12

Dentist as Expert 13

You re the doctor! 13

Dentist as estimator and advisor 15

Self interest 16

Pattern of practice 17

Ethical practice decisions 18

The importance of profitability 19

Owner versus Employee 20

Employee in a small private practice 20

Employee in large group practice 21

Employee in a public health setting 22

Employees in a dental support organization 23

Dental Board 23

Value of Treatment Alternatives 25

Standard of care 26

Appropriate pattern of practice 26

The wallet biopsy 27

Social Media and Ethical Behavior 28

Will Yelp destroy a practice? 29

Dissemination of fees 30

Future of Dental Ethics 31

What is future ethical behavior? 32

What is quality and who determines? 32

Conclusions 33

Chapter 8 Stay Out of Trouble
Matthew Cassady

Introduction 2

Fraud, Waste, and Abuse 4

Fraud 4

Waste 5

Abuse 7

Bad Behavior 8

Bill for services not rendered 8

Right a wrong 9

Undocumented treatment 10

Unnecessary service 12

Unbundle 14

Up code 14

Kickback 16

Alter date of service 16

Discount 17

Who s Looking? 19

Fraud, Waste, and Abuse in Your Office 26

How to avoid fraud, waste, and abuse 28

Record retention 33

Conclusion 40

Chapter 9 Analysis to Action
Michael Okuji

Introduction 2

Premise 2

Competition 4

Information 5

Small Private Practice 5

Streamline 8

Group Practice 12

Specialist group practice 13

Permanente Dental Associates 14

Dental group productivity 15

Group Practice System 16

Corporate practice of dentistry 17

Dental support organization 19

Competitive advantage 20

Re–brand 20

Off–brand 21

Integrate vertically 21

Spin–off service 22

New service 22

Partnership 23

Dentist training model 23

Hub & spoke 24

Safety Net System 25

Premise 26

Competitive strategy operations 26

Airline capacity model 27

Competitive strategy partnership 28

Competitive strategy leadership 29

Organized Dentistry 30

Quality 30

Tele–dentistry 32

Integrator Organized Dentistry 34

Group purchasing organization 34

Options for action 34

Integrator Independent Practice Association 37

Integrator Information Technology Company 39

Conclusion 41

Michael Okuji, DDS, MPH, MBA, is the Dental Director at Delta Dental of Colorado. Prior to working for Delta Dental, Dr. Okuji maintained a solo private dental practice for 35 years in San Francisco. He was also an Assistant Clinical Professor at the University of Southern California, Ostrow School of Dentistry and a Group Practice Director at the UCLA School of Dentistry. He lectures on insurance issues and practice management. Dr. Okuji is the author of the book Dental Practice: Get in the Game.