2. The Dentist’s Guide Understanding Your Patients’ Dental Benefits Dental Benefit Plans NYSDA

3. HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Table of Contents Dental Benefits Plan Provisions Types of Plans Fraud and Abuse Claim Submission FAQ’s Dental Benefits Benefit Plan Provisions Types of Plans Fraud and Abuse Claim Submission FAQ’s Table of Contents

4. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Table of Contents Dental Benefits Plan Provisions Types of Plans Fraud and Abuse Claim Submission FAQ’s What are dental benefits? Why employers offer dental benefits? Dental benefits and your practice Dental Benefits

5. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s What are dental benefits? Provisions in the contract between an employer and employee that helps cover the cost for the employee to maintain or improve their oral health.

6. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Companies give dental benefits to Decrease employee absences Prevent poor work performance Maximize profit margin Aid employee recruitment & retention Why Employers Offer Dental Benefits?

7. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Who has benefits? What are “benefit plan provisions?” How are “coordination of benefits” determined? Is there an “assignment of benefits?” Are “co-payments” due? Dental benefits and your practice

8. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Who has benefits? Patients must verify “eligibility” Verifying a patient’s coverage is a courtesy A patient may not be eligible for benefits Unless dentist is a “participating provider,” eligibility cannot be guaranteed Documentation of eligibility includes “effective date of coverage”

9. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Who has benefits? If applicable, the patient must know the “expiration date” There may be a period of limited coverage after the expiration date called an “extension of benefits”

10. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Table of Contents Dental Benefits Plan Provisions Types of Plans Fraud and Abuse Claim Submission FAQ’s Parameters in the patient’s plan that affect their reimbursement* These parameters will help in determining the coordination of benefits, the assignment of benefits, and the amount of co- payment. Benefit Plan Provisions *These provisions should never influence the quality of care delivered to the patient.

11. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Benefit Plan Provisions Limitations of Coverage LEAT or LEPAAT Pre-Existing Conditions Exclusionary Period Proof of Loss Coordination of Benefits Non-duplication of Benefits Maintenance of Benefits

12. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Limitations of Coverage Sometimes called “exceptions” or “exclusions” Restrictive conditions in a dental benefits contract affecting how an individual or group is covered

13. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Limitations of Coverage Examples: age restrictions –(ex.: sealants covered to age 12) time limitations –(ex.: children covered to age 21) waiting periods –(ex.: 3 months before coverage starts) benefit exclusions –(ex.: no orthodontics)

14. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Least Expensive Alternate Treatment LEAT, also called “the least expensive professionally acceptable treatment” (LEPAAT) Restricts benefit allowance to coverage for the least expensive method of treatment* *Determination of benefits is independent of the final treatment decision made by the dentist and the patient.

15. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Pre-existing Conditions An oral health condition that existed before the patient was enrolled in the dental benefit program Benefit plans will only cover a loss incurred while the patient is covered

16. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Pre-existing Conditions Example: A patient missing a 1st molar prior to coverage will not get a benefit for a fixed bridge or a removable partial denture

17. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Exclusionary Period The period of time, defined by the dental benefits contract, in which a reimbursable restoration or procedure is functional (its life-span)

18. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Exclusionary Period Example: If a replacement for a single crown will only be reimbursed if the original is greater than 5 years old then its exclusionary period is 5 years

19. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Proof of Loss Valid documentation of the covered patient’s treatment includes dates, costs, records, and approved codes and forms. This information is needed to determine the financial liability of the company providing dental benefit plan

20. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Coordination of Benefits When a patient is covered by more than one dental benefits plan The liability for each plan is determined by the contract

21. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Coordination of Benefits Coverage will be designated as “primary” and “secondary” with assigned liabilities, benefits for specific procedures, and reimbursements by the plan administrators.

22. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Non-duplication of Benefits By contract, many dental plans will not give a benefit if the plan is the patient’s “secondary” coverage.

23. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Non-duplication of Benefits Example: Patient will not receive 100% reimbursement for procedure usually reimbursed by either plan at 50% Patient will receive only the 50% from the “primary” coverage “Secondary” plan will not pay benefit because of non-duplication clause in the contract.

24. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Maintenance of Benefits Assuming that the benefit of the secondary coverage is higher than the primary The secondary coverage will reimburse the difference, if the allowable has already been met by the primary

25. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Maintenance of Benefits If the benefit of the primary coverage is equal or higher then the secondary coverage pays nothing. This preserves or maintains the benefit, at least to the level of the secondary coverage.

26. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Table of Contents Dental Benefits Plan Provisions Types of Plans Fraud and Abuse Claim Submission FAQ’s Fee-for-Service Managed Care Discount / Referral Types of Dental Benefit Plans

27. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Dental Benefit Plans Dental benefit plans generally are divided into two categories: –Fully insured –Self-funded

28. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Dental Benefit Plans Fully insured plans –The financial risk is transferred to the insurance company. –The plan and the insurance company are subject to state insurance laws and regulations.

29. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Dental Benefit Plans Self-funded plans –The worker’s employer, union, or group assumes the financial risk. –Self-funded plans are regulated primarily by U.S. Labor Department under federal ERISA statutes (Employee Retirement Income Security Act).

30. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Traditional Fee-for-Service Direct Reimbursement Indemnity Plans Fee-for-Service Dental Plans

31. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Dentist provides service Dentist determines fee Patient pays for service No coverage. No limitations No exclusions. No third party Traditional Fee-for-Service Dentist Patient Financial relationship Medical-legal relationship Traditional fee-for-service is not a dental plan, but is included in this presentation to provide us with the base line or null plan

32. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s DR is a self-funded dental benefits plan Employee pays for treatment from any dentist Employee reimbursed for dollars spent on treatment Direct Reimbursement

33. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Reimbursement dictated by employer’s plan design DR is ADA’s recommended form of 3 rd party reimbursement Coverage is limited to the money in the patient’s DR account maintained by the employer Direct Reimbursement

34. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Go to the ADA’s website for more info Direct Reimbursement Dentist Patient Financial relationship Medical-legal relationship Employer Financial relationship

35. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Fully insured or self-insured plans Patients receive benefits regardless of dentist they select Predetermined reimbursement for specific services, regardless of dentist’s actual charges Payments to enrollees or, with authorization, to dentist directly Indemnity Plans

36. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Fully insured indemnity plan relationships Indemnity Plans Dentist Patient Financial Medical-legal Financial (Reimbursement) Insurance Co.Employer Contractual Authorization

37. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Self-funded plan relationships Indemnity Plans Dentist Patient Financial Medical-legal Financial (reimbursement) Employer / Union / or Group Authorization

38. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Limit coverage by... –Using a “deductible” –Use of a “UCR schedule” –Having a “schedule of allowance” –Establishing an “annual maximum” –Paying for the “least expensive alternative treatment” (LEAT) Indemnity Plans

39. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Deductibles –A per patient or per family charge that is not reimbursed by the dental plan at the initial use of the plan for its calendar year –Requires patients out-of-pocket contribution to fee Indemnity Plans

40. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s The UCR Schedule –UCR = “usual, customary, and reasonable” –Actually benefit company’s proprietary basis for its reimbursement allowance –No defined relationship to any dentist’s actual fees Indemnity Plans

41. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s The UCR Schedule –Determined contractually between 3 rd party and plan purchaser –Provides reimbursement based on percentile of UCR schedule –“Co-payment” equals difference between plan’s allowable benefit and dentist’s actual fee Indemnity Plans

42. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Schedule of Allowance –Lists covered services and shows how much the plan will pay for each service. The patient is responsible for the difference, the “co-payment” Indemnity Plans

43. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Annual Maximum –Maximum amount that insurance plan will pay during a calendar year, after the patient has met required deductible –Establishes a limit of liability, per individual or family Indemnity Plans

44. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Indemnity Plans LEAT clause –Restricts benefit allowance to coverage for the least expensive method of treatment –Independent of the final treatment decision made by the dentist and the patient

45. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Preferred or Participating Provider Organizations (PPOs) Closed Panel PPOs Health Maintenance Organizations (HMO) Managed Care Plans

46. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Changes reimbursement –Plan may reimburse dentist directly –Patient may receive different reimbursement for using “in-plan” or “out-of-network” dentist Managed Care Plans

47. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Managed Care Plans Designed to reduce health care costs Presume over-utilization of treatment services Transfer portion of financial liability from 3 rd party and patient to doctor Reduce alleged “over-treatment” through financial disincentives to treat

48. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Managed Care Plans Requires dentist to contract with managed care company or other 3 rd party payer, directly or through subcontractor Subcontracting groups include: –IPA (Independent Practice Association) –PPO (Participating Provider Panels) –LLC (Limited Liability Corporations)

49. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Dentist’s fees limited by contract Services are either covered, or non- covered, or excluded from coverage Co-payment for non-covered or excluded services may be determined by contract, otherwise it is traditional fee-for-service Managed Care Plans

50. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Fully insured managed care plan relationships Managed Care Plans Dentist Patient Financial (non-covered) Medical-legal Insurance Co.Employer Contractual Financial (assignment)

51. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Self-funded managed care relationships Managed Care Plans Dentist Patient Financial Medical-legal Employer / Union / or Group Contractual Financial (assignment)

52. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Dentist Contracts - PPO Participating Provider Organizations [PPOs] Contract with dentists for fee discounts and other concessions Contract with insurance companies or benefit plans to offer discounted benefits through panel dentists

53. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Dentist Contracts - PPO Most common form of managed care in dentistry. Dentists negotiate individually with PPO.

54. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Dentist Contracts - IPA Independent Practice Associations [IPA] are a type of integrated group practice: i.e., P.C., LLC Therefore IPA can enter into contracts and negotiate fees on behalf of member doctors Contracts with doctor-members Contracts only with HMOs to provide dentists to treat HMO member-patients

55. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Dentist Contracts - LLC Limited Liability Corporations [LLC] are a type of integrated group practice: i.e., P.C. Therefore LLC can enter into contracts and negotiate fees on behalf of member doctors Contracts with doctor-members Contracts with PPOs, HMOs, or benefit companies directly to provide dentists to treat patients enrolled in discount dental plans

56. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Contract with dentists for discounted fees and other concessions May be fully insured (insurance company’s risk) or self-insured (employer’s risk) Cost employers less than similar indemnity plan Preferred Provider Organizations

57. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Employees select a dentist from a network. Employees may have to pay a co- payment to the dentist, depending on the service. Employees may have a point-of- service option. Preferred Provider Organizations

58. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Patients may receive some benefit even when treated by an “out-of-network” dentist. These patients get a significantly reduced benefit. Patients pay the difference. Point-of-Service Option

59. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Plan makes no reimbursement when care is provided by non- participating dentist Closed Panel PPO

60. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Health Maintenance Organizations Contracts with individual dentists or groups (e.g. PPOs, IPAs, etc.) Benefit paid directly to providers, not patients Patients restricted or encouraged to see enrolled doctors to receive benefits

61. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Health Maintenance Organizations Transfers financial liability from third-party and/or patient to dentist Provides financial disincentives to treatment Popular with employers to reduce costs of health benefit package

62. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Reimbursement in Managed Care Fee-for-service Capitation

63. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Reimbursement in Managed Care Dentist contract with benefit plans or group to accept specific fees from plan Fees may be discounted or eliminated Fees may be supplemented by fixed patient co-payments Certain procedures may not be covered Dentist may forfeit ability to collect from patients for certain treatment

64. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Reimbursement in Managed Care: Capitation Fixed monthly payment, per patient or family, regardless of services rendered Does not alter dentist’s fiduciary responsibility to deliver appropriate care

65. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Reimbursement in Managed Care: Capitation Dentist’s income determined by: –Negotiated capitation fees to dentist –Size of enrolled panel assigned to dentist –Period of patient enrollment –amount of treatment required by patients in panel

66. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Discount / Referral plan relationships Discount / Referral Dental Plans Dentist Patient Financial Medical-legal Third Party Marketers Contractual Financial Contractual

67. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Third party marketers establish schedule of fees Dentists contract with third-party marketer to charge enrolled patients based on established fee schedule Discount / Referral Dental Plans

68. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Discount / Referral Dental Plans Patients enroll for a monthly charge Patients given list of contracted dentists Dentists discount their normal fees in exchange for prospective referrals

69. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Discount / Referral Dental Plans Plan pays no actual benefits Patients pay all dental fees directly to dentist “Coverage” limited to fee discount in dentist’s contract with marketer Non-listed services may be discounted as per the contract, otherwise traditional fee-for- service

70. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Table of Contents Dental Benefits Plan Provisions Types of Plans Fraud and Abuse Claim Submission FAQ’s Examples of Fraud and Abuse Fee Forgiveness Coupons False Diagnosis Claims Padding Misrepresentation

71. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Examples of Fraud and Abuse Over-utilization Refund of fee to patient Upcoding Unbundling Billing for services not performed Other Fraudulent Schemes

72. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Actions Against Fraud and Abuse Restitution Civil litigation Criminal prosecution Professional Discipline

73. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Actions Against Fraud and Abuse Professional Discipline: –censure –fines –license probation –license suspension –license revocation

74. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Plan Regulation Plans are regulated by NYS Insurance Laws Managed Care Plans (HMOs) also regulated by NYS Department of Health Self-funded plans are regulated by US Department of Labor

75. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s How to Remediate Plan Violations Violations of Managed Care Contracts –Dentist may impose sanctions defined in contract –Dentist should consult with attorney regarding contract violations

76. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s How to Remediate Plan Violations Patient Contract Violations –Utilize appeal procedures –Complain to plan –Complain to plan purchaser (i.e. employer) –Complain to NYS Insurance Dept. –Complain to US Dept. of Labor (self- funded plans) –Consult with attorney

77. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Table of Contents Dental Benefits Plan Provisions Types of Plans Fraud and Abuse Claim Submission FAQ’s Claim Submission Patient claim must specify type of treatment received Date of service Name of treating dentist Dentist’s actual fee for patient’s treatment

78. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Claim Submission Dentists are not required to submit patient claims Dentists under contract to a managed care company may be contractually obligated to submit claims for enrolled patients

79. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Claim Submission Claim forms may allow patient to authorize payer to send insured’s benefit directly to the treating dentist This is purely a courtesy Authorization is NOT binding on the payer

80. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s When Submitting Claims... Dentist must provide –Accurate patient & provider information –Accurate treatment information Date of treatment Types of treatment (CDT codes) –Accurate fee information –Timely claim submission –Copies of records, when requested

81. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Substitute Benefits – CDT Code Changes Carrier extends alternate benefit when treatment service is not covered Payment made for less expensive alternative when service is not covered If service is covered, alternate treatment must be clinically appropriate for patient

82. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s 3 rd Party Dental Consultants Anyone may determine whether the policy covers services and patient is eligible for benefits When rendering decisions about quality or appropriateness of patient care –Must be licensed dentist in state where patient is treated –Evaluating patient care and treatment planning are facets of the practice of dentistry –All state regulatory statutes and guidelines apply

83. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s When may 3 rd party deny a claim? (Indemnity) Patient not covered by policy Services not performed Dentist did not charge patient for treatment Services not covered Services exceed policy limitations Deductible not met Patient benefits expended Benefits received exceed plan allowable Claim submitted beyond allowable time limit

84. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s When will 3 rd party payer deny a claim? (Managed Care) Dentist not under contract in “closed panel” plan Services excluded from coverage Services do not conform with plan definitions for “medical necessity” or “standard of care” Dentist’s maximum reimbursement exceeded

85. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s When must a 3 rd party payer pay a claim? Patient enrolled in plan Treatment services covered Treatment within policy guidelines Patient eligible for benefits Deductible has not been met Annual maximum not reached Allowable reimbursement not met by second carrier

86. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s When can claim denials be appealed? Treatment is covered by policy Patient eligible for benefits Denial based on “standard of care” Denial based on “least expensive alternative treatment” clause – and alternative is not clinically appropriate for patient Denial based on “medical necessity” Question about qualifications of consultant

87. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s How can denials be appealed? 3 rd party payer must provide internal review of disputed claim 3 rd party payer must then provide objective external review Peer Review – under certain conditions Patient may sue for contractual violations Possible 3 rd party legal violations –Complain to NYS Insurance Department –Complain to self-funded plan under ERISA to US Labor Department

88. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Assignment of Benefits In true “assignment,” the doctor becomes the benefit recipient; e.g., No-Fault, Medicaid, some managed care If payment is disputed, the doctor engages in the dispute If no benefit is available, the doctor loses recourse to seek payment from the patient

89. NYSDA HomeHome / Dental Benefits / Benefit Plan Provisions / Types of Plans / Fraud & Abuse / Claim Submission / FAQ’sDental Benefits Benefit Plan Provisions Types of Plans Fraud & Abuse Claim Submission FAQ’s Frequently Asked Questions E-mail questions to NYSDental.org Responses will be e-mailed back New dental benefit info will be posted on this site.