Committee on Dental Benefits

1Committee on Dental Benefits 2June 25, 2010 3Page 1 of 6 1 Committee on Dental Benefits 2 Meeting 3 June 25, 2010 4 5 Minutes 6 7Present Absent 8Dr. David Fox (2) Dr. Thomas Donahue (3) 9Dr. Tad Glossner (5) Dr. Joseph Yatko (6) 10Dr. Robert Callahan (7) Dr. Jon Johnston (8), ADA Consultant 11Dr. Naila Naseem-Elkassas (8) 12Dr. Ronald Helminski (9) Consultants/ Staff/Guests 13Dr. Gino Pagano (10) Dr. Clayton Pesillo, UCCI 14Dr. Donald Stoner (10), T/L Mr. James Shade, UCCI 15Dr. Lauri Passeri (2), ADA Consultant Ms. Karen Witelsal, UCCI 16 Dr. Jerome Blum, UCCI 17 Dr. William Spruill (5), President 18 Ms. Marisa Swarney, director, government 19 Relations 20 21Welcome/Chair’s Remarks 22Dr. Glossner welcomed new members to the committee. 23 24Approval of Minutes 25The committee unanimously approved the minutes from the December 4, 2009, 26conference call. 27 28Meeting with United Concordia (UCCI) Representatives 29The committee asked and received answers to the following questions: 30 31 Question: What is the clinical rationale to justify UCCI’s policy that a dentist cannot 32 perform scaling and root planing 45 days before or after (or the same day) the dentist 33 performs a prophy? 34 35 Answer: Due to misreporting by participating providers, UCCI had to establish a 36 length of time. Its system can only account for a 45-day period, but it is reviewing 37 whether the system can be changed. However, UCCI believes it is inappropriate for 38 dentists to perform scaling and root planing, then perform a prophy, when periodontal 39 disease had been identified. Dentists should perform periodontal maintenance instead 40 of prophys. UCCI’s policy is to question a claim if a prophy falls within 45 days of 41 scaling and root planing. UCCI believes that dentists are performing a palliative 42 treatment and can be coded as such. UCCI believes that dentists who see patients for 43 gingival abscesses should treat those abscesses and submit it as a palliative treatment

4I:worddoc/Marisa/cdp/minutes_june10.doc 5 6These minutes are confidential and are not for distribution outside of the Committee on Dental Benefits and 7the Board of Trustees. 8 9Committee on Dental Benefits 10June 25, 2010 11Page 2 of 6 44 or an I and D. Either of those codes may be used for this entity, but S/RP 1-3 teeth 45 per quad will not be approved for treatment of a gingival abscess if there is no 46 radiographic evidence of bone loss. Dr. Blum suggested that PDA consult the ADA 47 for a different code for scaling of a gingival abscess if the current codes were not 48 inclusive enough. 49 50 The committee requested that UCCI consider shortening the 45-day timeframe to 14 51 days, based on studies indicating that most patients recuperate within a two-week 52 period and their gingiva is sufficiently healed. 53 54 Question: What is the clinical rationale for UCCI’s policy relating to Code 0140 that 55 suggests dentists should render treatment without first performing an examination and 56 diagnosis? This insurance policy is counter to the State Board of Dentistry 57 requirements found under the definitions of direct and general supervision. 58 59 Answer: UCCI believes the committee’s question is incorrect. This used to be 60 UCCI’s policy but it changed three years ago. UCCI will now pay dentists for 61 submitting claims for an examination, diagnosis and treatment given on the same day 62 to patients who come in unexpectedly. If this happens twice in one year, UCCI will 63 consider this an “uncovered billable” procedure and patients may be charged for the 64 second visit. 65 66 Question: What is the clinical rationale behind making 0460 a non-integral procedure 67 if performed on a day different than the day that the root canal procedure is 68 performed? How does UCCI determine what is integral to a procedure when there are 69 separate ADA Codes? 70 71 Answer: UCCI considers pulp testing integral to all procedures and is rarely 72 considered a separate procedure payable. If pulp testing is performed on a different 73 day as other procedures, UCCI may consider it an “uncovered billable” procedure and 74 patients may be charged, in the rare instances that a group requests that this be a 75 covered procedure. This is the exception rather than the rule. 76 77 Question: What is UCCI’s policy for assigning benefits when policyholders choose a 78 dental provider outside of the network? 79 80 Answer: UCCI considers it a benefit for providers who participate in its plans. 81 Pennsylvania is the only state as a whole that does not allow for assignment of 82 benefits. However, there are limited cases where they will assign benefits if the 83 employers’ group requests it. UCCI is considering removing this restriction overall. 84 When dealing with divorced parents, arrangements for insurance payments must be 85 made through a legal settlement or court order. Dentists should consider collecting 86 the payment up front and letting the parents settle the issue themselves. 87

12I:worddoc/Marisa/cdp/minutes_june10.doc 13 14These minutes are confidential and are not for distribution outside of the Committee on Dental Benefits and 15the Board of Trustees. 16 17Committee on Dental Benefits 18June 25, 2010 19Page 3 of 6 88 The committee noted that patients have the ability to talk to their employers about 89 requesting an assignment of benefit from UCCI. 90 91 Question: Please explain the new policy that requires general dentists to have to 92 supply more documentation than periodontists in order to have scaling and root 93 planing preauthorized. Does this apply to participating general dentists only? 94 95 Answer: The policy applies to all general dentists, not just participating providers. 96 The letter sent to providers included the misprint that the policy would only apply to 97 participating providers. In a pilot program in California, UCCI found that more 50 98 percent of general dentists are misreporting the presence of periodontal disease before 99 performing scaling and root planing. According to UCCI, it is their impression that 100 many general dentists believe that the mere presence of subgingival calculus indicates 101 a need for scaling and root planing. 102 103 The committee agreed to research whether dental school periodontal programs’ 104 classification of periodontal disease coincides with the American Academy of 105 Periodontists’ definitions of periodontal disease, and whether either of these coincides 106 appropriately with UCCI’s definition and treatment authorizations. The committee 107 will publish information for members to suggest an appropriate way to file claims to 108 UCCI using the correct definitions regarding periodontal disease. (06/10CDBDA1) 109 110 Question: Does UCCI adjudicate claims in the United States? 111 112 Answer: Yes, and there are no plans to move claims processing outside of the United 113 States. 114 115 Question: Is there any advantage to sending pans and photographs with claims 116 submission? 117 118 Answer: Yes, though radiographs and charts are paramount to approving claims. 119 120 Question: If preauthorization is needed for scaling and root planing, is it appropriate 121 to perform a debridement, then chart on the same day or subsequent to the visit? Will 122 the debridement, scaling and root planing all be paid for? 123 124 Answer: That is appropriate and UCCI will pay for debridement (D4355) and scaling 125 and root planing or a prophy, as long as they are not done on the same day. (It is not 126 appropriate to do a comprehensive exam on the same day as performing code D4355). 127 There does not need be 45 days between the debridement and scaling and root 128 planing.

20I:worddoc/Marisa/cdp/minutes_june10.doc 21 22These minutes are confidential and are not for distribution outside of the Committee on Dental Benefits and 23the Board of Trustees. 24 25Committee on Dental Benefits 26June 25, 2010 27Page 4 of 6 129 Question: Does UCCI lease its network? 130 131 Answer: UCCI does lease its network outside of Pennsylvania. In Pennsylvania, all 132 business is under UCCI with one exception of having business with Mutual Omaha. 133 134 Question: Will UCCI withhold claims if requesting reimbursement for a previous 135 claim? 136 137 Answer: UCCI may withhold claims, but only under extreme circumstances because 138 this practice can be challenged in court. UCCI’s policy is to first request the money 139 back and work with the provider to settle the issue. 140 141 Question: Can dentists participate in UCCI’s Children Health Insurance Program 142 (CHIP) without participating in all UCCI ‘s plans? 143 144 Answer: Yes, dentists may now participate in CHIP without participating in UCCI’s 145 commercial plans. UCCI is contracted with Highmark to administer CHIP. 146 147Insurance Liaison Program 148The following members of the committee agreed to serve as liaison to dental insurance 149companies: 150 151MetLife: Dr. Joseph Yatko 152UCCI: Dr. Tad Glossner and Dr. Gino Pagano 153Delta: Dr. Robert Callahan 154Aetna: Dr. Ronald Helminski 155Cigna: Dr. Naila Naseem-Elkassas 156Guardian: Dr. Lauri Passeri 157Miscellaneous: Dr. Gino Pagano 158 159Review of Boilerplate Letter to Members 160The committee reviewed the draft letter PDA will send to any member who calls with an 161insurance complaint. It was agreed that the letter should include language encouraging 162members to read insurance contracts carefully and use the American Dental Association’s 163(ADA) Contract Analysis Service before signing contracts. 164 165Staff will revise the draft letter to members who contact PDA with insurance complaints, 166advising them to read insurance contracts carefully and use the ADA’s Contract Analysis 167Service. Staff will post the revised letter on the committee’s social networking page for 168final review (06/10CDBDA2) 169 170Legislative Update 171The committee reviewed SB 1222, legislation prohibiting insurers from capping non- 172covered services. Dr. William Spruill explained that legislators are debating whether to

28I:worddoc/Marisa/cdp/minutes_june10.doc 29 30These minutes are confidential and are not for distribution outside of the Committee on Dental Benefits and 31the Board of Trustees. 32 33Committee on Dental Benefits 34June 25, 2010 35Page 5 of 6 173add language to SB 1222 that would prohibit dentists from charging their usual fees for 174covered procedures in situations where patients exhaust their maximum allowance in a 175given year. 176 177A majority of the committee agreed that PDA should continue lobbying for the passage 178of SB 1222 without amendments. However, if it becomes clear that SB 1222 will “die” 179without an amendment that prohibits dentists from charging their usual fees for covered 180services when a maximum yearly benefit is met, the committee recommends adding the 181amendment to ensure passage of SB 1222. Dr. Spruill will forward the committee’s 182recommendation to PDA’s Board of Trustees for consideration should it become 183necessary as SB 1222 moves through the legislative process. (06/10CDBDA3) 184 185Staff will post on the committee’s social networking page for review the National 186Conference of Insurance Legislators’ model legislation prohibiting insurers from capping 187non-covered services. (06/10CBDDA4) 188 189HB 2509, legislation requiring insurers to assign benefits to non-participating providers 190directly after treatment is rendered to a subscriber, was assigned to the House Insurance 191Committee in May. It will most likely “die” at the end of the legislative session in 192November and will need to be reintroduced next session. 193 194Member Resources 195The committee agreed to the following: 196 197 Dr. Lauri Passeri will research whether it would be beneficial for PDA to contract 198 with Trojan Software, which provides important insurance coding and billing 199 information, in order to offer its services to members for a discounted fee. Dr. Passeri 200 will report her findings to the committee during its October 27 conference call. 201 (06/10CDBDA5) 202 Staff will research whether it would be beneficial for PDA to contract with Insurance 203 Solutions in order to offer its services to members for a discounted fee. The Insurance 204 Solutions newsletter answers questions for members who have problems with 205 insurance companies. Staff will reports their findings to the committee during its 206 October 27 conference call. (06/10CBDDA6) 207 The committee will develop a schedule for sending insurance-related information to 208 members via email on a monthly basis. Staff will work with Dr. Glossner to develop a 209 list of topics and a schedule for when articles are due. Each committee member is 210 responsible for writing at least one article by the established deadline. 211 (6/10CBDDA7) 212 Dr. Tad Glossner will research whether PDA can offer continuing education (CE) 213 courses on proper coding and claims submission. The ADA may have speakers 214 available for CE courses. (06/10CBDDA8) 215

36I:worddoc/Marisa/cdp/minutes_june10.doc 37 38These minutes are confidential and are not for distribution outside of the Committee on Dental Benefits and 39the Board of Trustees. 40 41Committee on Dental Benefits 42June 25, 2010 43Page 6 of 6 216New Business 217Dr. Passeri recommended that PDA send a representative to attend the ADA’s National 218Benefits Conference on August 20, 2010, in Chicago. Staff will forward a request to 219PDA’s Budget, Finance and Property Committee to fund one representative’s attendance 220at the conference. (06/10CBDDA9) 221 222The committee scheduled a conference call for Wednesday, October 27, 2010, at 7:00 223p.m. 224 225The meeting adjourned at 2:03 p.m.

44I:worddoc/Marisa/cdp/minutes_june10.doc 45 46These minutes are confidential and are not for distribution outside of the Committee on Dental Benefits and 47the Board of Trustees. 48