Dental trauma continues to be a major area of cost and remains a concern in the claim community. The biggest type of problem claim today involves teeth that were broken down due entirely to pre-existing deterioration, not at all related to the injury claimed to have caused, or aggravated the condition.
In other words, many of the claims for broken teeth may be classified as false or exaggerated, or even fraudulent, since the condition in need of treatment was pre-existing (not accident related). The cost of many of these claims begin at $1,000 (root canal, post, and crown) and many are much more costly (bridges, implants, TMD, etc.)
Thus, it is increasingly important to have all dental injury claims reviewed for causal relationship, not simply for appropriate treatment and consideration of the fees.
While TMD (temporomandibular joint dysfunction) has leveled off in recent years, and is not expected to be the problem it was a few years ago, much of the credit for this belongs to the nationwide review of these problem claims by NADENT (See Section D3 for a more in-depth discussion of TMD).
NADENT's consultants were, and are able to incorporate the most up to date research of TMD into the claim review process, providing recommendations to the claims representatives that fit the most current scientific findings in the field of dentistry. With continued review of these claims by NADENT, claim representatives can be sure that inappropriate submissions for TMD can be detected, and denied, preserving funds for legitimate claims.
One of the main causes for the spiraling increase in dental trauma claims is the technical language that the dentist uses in the submission of those claims. This and many other confusing aspects of these claims make resolution particularly difficult for the claim representative.
This a prime reason for the development of the Dental Trauma Review Program.
Following the Dental Trauma Review Program procedures should effect substantial savings by restricting payments to only those charges which are truly the responsibility of the insurance carrier, not to charges that were for pre-existing conditions.
The program objective is to effect significant savings in dental trauma claims through the implementation of the Dental Trauma Review Program. Since there is no significant historical data on the extent of loss payments due to dental trauma, it is difficult to set a numerical dollar savings objective. Based on recent indications, however, somewhere between 20 and 30 percent of gross billings is possible. In addition, since savings are a function of the number of dental trauma reviews, the insurer should obviously strive for the maximum number of reviews possible.
NADENT, a division of National Dental Consultants, Ltd. ("NDC") has been selected by many major insurance carriers as the firm to provide a Claims Service with dental trauma consultation. NADENT provides extensive dental consulting services in all fifty states through a network of acknowledged professionals. NADENT has agreed to provide all insurance companies with a computerized activity report which will relieve field claim offices from having to maintain manual records.
All dental trauma claims must be reviewed carefully to ensure that allowances are restricted to dental trauma costs for which the insurer is responsible. The following situations would suggest a need for dental consultation:
any request for orthodontic treatment.
time delay in seeking dental treatment.
an allegation of dental trauma, with no mention of any facial or dental injuries, and no head or neck x-rays taken or submitted.
any allegation of TMD (temporomandibular joint) dysfunction;
(Refer to section D3 for an in-depth discussion)
indication of a need for extensive periodontal therapy.
any allegation as to the necessity of life-long dental treatment.
cases in which dental treatment exceeds $300.00.
cases in which the claim - regardless of amount - appears to be questionable.
alleged teeth injuries too spread out, i.e. T#3, 14, 19, 30,
etc.
(Refer to section D2).
Dental trauma losses requiring a consultation should be assigned within ten working days of receipt of claim unless contraindicated by claim management strategies or statutory laws and attendant rules and regulations. The assignment for a consultation must be by letter. NADENT has a preprinted assignment form; use of the form will thus satisfy the letter requirements. The consultation fee should be paid within ten working days of receipt of a satisfactory consultation report.
NADENT is a professional dental consulting firm headquartered at 355 Main Street, Islip, NY, 11751, (631) 581-2350, offering service in all states as well as Puerto Rico and the Virgin Islands. To help speed the delivery of services, NADENT has established five facilities, in addition to their main office. Analysis can be made promptly at all offices and consultations for special reviews and examinations can be made as necessary, without delay.
NADENT's services consist of:
Analyzing medical reports (emergency room report, accident reports, treatment plan, narrative report, x-rays) within two weeks.
Performing thorough examinations in close proximity to the claimant's home.
Appearing for depositions and providing expert witness in court on the insurance carrier's behalf.
Providing computerized reports of quarterly consulting activities.
NADENT is committed to providing a level of service which will help the claim handler maintain a good relationship with insured's representatives and insureds.
Following the recommended assignment procedure, NADENT will, in most instances, be able to send you a written report within two weeks of the time they secure the information. Send NADENT the following information:
Completed Claim Review Form. Additional forms can be obtained by calling NADENT directly, or by printing the claim form from this web site.
X-rays taken by the attending dentists at the time of trauma (if you have a problem obtaining the x-rays, it may be helpful to inform the attending dentists that they will be reviewed by a licensed dentist. Another helpful approach would be to request that the attending dentists refer the x-rays directly to NADENT. This is best confirmed by a letter with a copy to NADENT).
The attending dentist(s) report, treatment plan and fees.
The accident report (first report of injury).
The hospital emergency room report (if applicable).
Other information pertinent to dental issues.
TMD Claims: In addition to the above, a narrative from the attending dentist and any information that is pertinent to the claim from other providers (neurologists, orthopedists, chiropractors, diagnostic reports, etc.).
This position paper of NADENT, regarding claims policy for TMD (Temporomandibular Disorders) was prepared by NADENT.
Insurance Companies which write medical and/or dental benefit plans for trauma have, for several years, been receiving claims from physicians and dentists who treat what have traditionally been referred to as "TMJ" (temporomandibular joint) problems. There has been a considerable amount of confusion as to how these claims should be handled. The net result of the policy of most companies to date is that this complex of disorders is covered under either medical or dental plans and may be abused in trauma claims.
This letter from NADENT is to present our recommendations of guidelines for claims processing, based on guidelines for diagnosis and treatment which have been recently developed by recognized national leaders in the treatment of craniomandibular (TMD) disorders, many of whom are consultants with NADENT.
The disorders of the craniomandibular articulation, the area where the lower jaw hinges into the upper jaw (temporomandibular joint) and associated muscles and ligaments, are similar to those of other joint systems which fall within the area of physical medicine. The one area for which there is no formal training in either medical or dental curriculums (undergraduate or graduate) is that of the craniomandibular complex of joints, muscles and ligaments.
The medical specialty of orthopaedics does not generally consider musculoskeletal problems of the head to be their responsibility. Therefore, the problem of treating those disorders has been given over to the dental profession.
As in the treatment of injuries and disorders of other joints where splinting and bracing are required, the treatment of the craniomandibular complex frequently requires the use of a splint or brace. Disorders of the knee joint may be used as a close approximation of what must be done with the craniomandibular articulation. Support and stabilization of the knee is done by means of a brace which allows hinge movement but which restricts side to side rotation.
In much the same way (although the potential movements are different), the splint used to support and stabilize the complex can be used to limit, restrict and control the amount and direction of jaw movement. In this way, these splints are truly orthopaedic in nature.
Some confusion exists about the nature of these splints due to the fact that the teeth provide a convenient means of providing secure anchorage for them. They have, therefore, been erroneously referred to as "dental appliances" or "orthodontic appliances" by the insurance industry. Their purpose is almost never intended to affect the teeth and their use, therefore, should not be considered dental.
There are procedures used in the treatment of the disorders of the "craniomandibular complex" which should properly be considered "dental" in nature. The authorities in the field have established quite clear guidelines in their comprehensive approach to the management of disorders of the craniomandibular complex.
Through the use of these guidelines, a clear distinction can be drawn, for insurance purposes. NADENT recommends that insurance companies adopt the following guidelines for the handling of insurance claims for any of the several medical disorders known broadly as "TMD" or craniomandibular disorders.
DIAGNOSIS:
1. Benefits should be considered under medical plans for diagnostic procedures related to craniomandibular (TMD) disorders, provided that the attending dentist includes at a minimum, the following:
A. Complete medical and dental history and a complete history of the pain dysfunction complaint.
B. Complete clinical examination appropriate to the complaint.
C. Minimum X-rays necessary to make treatment choices.
D. Diagnostic study models may be indicated.
2. When requesting pre-determination of benefits:
A. The diagnosis of the disorder(s) must be specific and definable by the appropriate ICD-9 code(s). Possible or probably diagnosis should be provided with appropriate ICD-9 codes.
B. An itemized treatment plan with appropriate CPT codes must be included.
The guidelines established by recognized authorities in the field recommend that therapy, whenever possible (in the vast majority of cases) be designed to relieve symptoms, encourage healing (repair and regeneration), promote behavior modification where indicated, and to achieve patient comfort. This is of primary consideration in trauma cases. Treatment modalities appropriate to Phase I include, but are not limited to, the following:
The use of orthopaedic splint therapy together with Phase I therapies is designed to relieve symptoms and to achieve where indicated, stabilization, dynamic bracing, and/or a repositioning of the mandible (lower jaw) which contributes to the resolution of the disorder. Phase I Therapy is commonly the endpoint of therapy.
In cases of trauma, the insurance company's responsibility may end with completion of Phase I Thearpy. This must be determined in the individual case by the NADENT consultant..
Certain diseases of the craniomandibular complex will require invasive and/or non-reversible Phase II therapy. Such disorders may include certain disc displacement problems, bony fibrous ankylosis of the joint, a fractured displacement, tumors, or gross developmental abnormalities. These are realtively rare conditions.
Additional therapy may be justified only if certain criteria are met. Phase II thereapeutics may include one or more of the following:
1. Occlusal adjustment of the teeth (equilibration)
2. Restorative treatment
3. Prosthodontic treatment
4. Full-mouth rehabilitation
5. Orthodontic treatment
6. Orthognatic surgery
Requests for pre-determination of benefits of Phase II therapy
which omit Phase I modalities should not be considered.
In certain cases, the consultant may request that the treating
doctor provide the mounted casts and bite registrations for evaluation,
or other additional information.
Due to the complex nature of these disorders and the variety of treatment modalities that are currently employed, it is advisable to refer these claims to NADENT. It should also be noted that many post-trauma facial or joint pains may be unrelated to the TMJ. Referred pain from nearby sites is common in the head and neck region and accounts for frequent errors in diagnosis and treatment.
NATIONAL DENTAL CONSULTANTS, LTD.
("NADENT") Revised 2001
