Dental and medical plan cooperation is still in its infancy, but more carriers are offering benefits for patients with systemic disease. As these benefits become defined, hygienists can help their patients factor in how their insurance can contribute to the total cost of treatment.
by Carol Tekavec, CDA, RDH
Hygienists are often given the task of providing education to patients concerning the impact of oral disease on systemic disease and vice versa. Dental providers have long known about the relationship between the health of the mouth and the rest of the body, despite the fact that dental and medical benefits have separated the two. Now the rest of the world is catching up! Dental disease and diseases and conditions of the body are in the news. Research is backing up observations that bacterial infection and tissue inflammation in the mouth can be a factor in the development of diabetes, heart disease, stroke, and other serious problems. Because of this, a few dental benefit companies have recently begun to offer additional “hygiene” service provisions, either as part of a dental plan or as part of a medical management plan.
For example, a few Cigna medical plans are offering extra “cleanings” for diabetic patients who are also enrolled in a designated “disease management” program. In other words, diabetics who have both a medical and dental plan through Cigna may be eligible to have an additional “cleaning,” which would be covered by the medical side. In addition, Cigna is said to now provide an additional “cleaning” beyond the typical two per year as an added benefit for pregnant women.
Delta of Virginia has also recently added a benefit designed to address ongoing research indicating that incidences of premature, low-birth-weight infants may be related to oral conditions. As of Jan. 1, 2007, pregnant women can receive one additional teeth cleaning (D1110) or periodontal maintenance (D4910) if they have a history of past periodontal surgery. The benefit is extended to diabetics as well. Aetna, Travelers, other Delta plans, and other insurers are also beginning to provide additional “preventive” and “therapeutic” benefits.
Because scientific evidence shows that preventing or treating oral conditions can improve general health, the demand from consumers for additional benefits is also increasing. News reports concerning oral topics are becoming widespread on television, in newspapers, and on the Internet. As patients learn more about infection and inflammation and their relationships to health, dental treatment becomes more important to them.
“Disease management” is another new focus. Managing general health conditions, such as diabetes and heart disease, has been shown to help control health outcomes and, therefore, health costs. Insurance companies have an interest in holding down costs, so many companies have expanded their disease-management programs. Because oral and general health issues are shown to be intricately involved, disease management that takes into consideration oral conditions is on the rise.
According to the March 2007 issue of the “Managed Dental Care Newsletter,” several studies are underway at the University of Michigan in Ann Arbor and the University of Detroit-Mercy (with support from Delta) demonstrating that when diabetics receive an adult prophylaxis, their blood sugar levels are easier to control for a period of time.
Some plans are even looking at expanded preventive benefits for individuals who are not suffering from periodontal disease, but who are “at risk” for the disease. Additional “cleanings” and/or periodontal maintenance, preventive topical fluoride, and even dental sealants for adults are being considered.
Chairside or laboratory tests for periodontal bacteria have yet to be mentioned for coverage by many plans; however, the dental profession’s increased focus on such testing to identify at-risk individuals may influence this situation to change as well.
Dental and medical plan cooperation is still in its infancy. As more carriers define their oral health-care service benefits as either medical or dental or both, offices will need to learn the best ways of dealing with filing claims. Right now, all dental plans and dentists must use the Current Dental Terminology-CDT 2007-2008 ADA codes for claims. The standard ADA Dental Claim Form or an individual dental plan claim form may be used. Filing claims on the medical side typically involves the use of an HCFA 1500 form as well as both a diagnosis code and a treatment code - not a CDT code. For the near future, it is important for offices to investigate their patient’s individual coverage. Patient claim stipulations and/or claim instructions can usually be located on the insurer’s Web site or in the patient’s employee benefits booklet.
What Can a Hygienist Do To Help?
What can a hygienist do to help patients understand the relationship between oral and general health as well as how insurance fits in to the picture? As one of the primary educators in a dental office, hygienists can provide a very valuable service for patients. Hygienists have an extensive background in the general health sciences and can often relate their knowledge to patients in a matter-of-fact way. Patients frequently see their hygienist for longer periods than their dentist. The hygienist is in a prime position to promote an expanded patient appreciation of the relationships between oral and systemic disease as well as some philosophical ideas concerning treatment, health, and costs. See the accompanying sidebar for some ideas to try with your patients.
Learn About Insurance To Help Patients
While front-desk staff frequently deal with insurance and finances, it is also helpful when the clinical team understands a little about how insurance works as well. Insured patients typically receive more treatment and more complete treatment than uninsured patients. Therefore, it often benefits the patient, the office, and the hygienist to help patients factor in their insurance’s contribution to the total cost of treatment. Dental benefits, though often limited in nature, can still help!
About the Author
Carol Tekavec, CDA, RDH, is a practicing dental hygienist, the author of the Dental Insurance Coding Handbook, the designer of a patient chart endorsed by the Colorado Dental Association, and the author of an informed consent treatment-specific booklet/CD. She is also the author of several patient brochures, including “What Is the Difference Between a ‘Regular’ Cleaning, a Root Planing, and Periodontal Maintenance?” and “Your Mouth Can Make You Sick.” She has appeared at all major dental meetings and is a presenter for the ADA Seminar Series. Contact her by phone at (800) 548-2164 or visit her Web site at www.steppingstonestosuccess.com.
Tips To Tell Patients
Here are some ideas to help your patients understand the relationship between oral and systemic disease, as well as ideas concerning treatment, health, and costs:
- Advise patients to visit the dentist as frequently as he or she recommends. Let patients know that dental care and management are important to their overall health and well-being.
- Talk to patients about the fact that even if they have insurance, it may not cover everything. Approach the subject in a nonaggressive, nonconfrontational way, Stressing that any amount covered can be a financial help. (Read the patient brochure “My Insurance Covers This ... Right?” at www.steppingstonestosuccess.com.)
- Discuss the fact that dental benefits should not be the sole consideration when making a decision about treatment. People who have lost their teeth often say that they would pay any amount of money to get them back. A person’s smile, attractiveness, ability to chew and enjoy food, and general sense of well-being are dependent on dental health. Now we know that general health is impacted as well.
- Explain to patients that the old standard of “twice-a-year cleanings” for everyone doesn’t make sense anymore.
- Use brochures and handouts to support explanations about the need for periodontal diagnosis, treatment, and recall. (Read the patient brochure “Your Mouth Can Make You Sick” at steppingstonestosuccess.com.)