Michael Kanellis, DDS, MS ADEA BFACA Mid Year Meeting October 17, 2014

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Transcription:

Michael Kanellis, DDS, MS ADEA BFACA Mid Year Meeting October 17, 2014

Michael Kanellis, DDS, MS ADEA BFACA Mid Year Meeting October 17, 2014

Implemented May 1, 2014 100,000+ low-income adults not eligible for Medicaid Comprehensive dental benefits Unique program design based on earned benefits and personal responsibility The only earned benefits program of its type in the nation

Designed to address concerns about Medicaid Administered by Private Insurance (Delta Dental) Higher reimbursement rates Promotes personal responsibility by patients Incentives to patients: more benefits if they return for preventive visits Incentives for dentists: bonus paid out based on percent of patients receiving oral health risk assessment

Previsor online oral health risk assessment Caries risk Periodontal risk Oral cancer risk Dentists get paid to do risk assessment Eligible for additional bonus payment Dentists get paid to provide oral health education

Three tiers of benefits Patients earn next tier of benefits by returning for a recall within 6-12 months No Co-Pay No Deductible No Annual Maximum

CORE Diagnostic Exams X-rays Preventive Cleanings Emergency Extractions Oral Surgery Stabilization ENHANCED All Core, plus: Restorative Root canals Non-surgical perio Oral Surgery Etc. ENHANCED + All Core, plus: All Enhanced, plus: Tooth replacement Gum Surgery

Core Benefits (tier 1) Emergency Care Diagnostic and Preventive Care Stabilization Services Enhanced Benefits (tier 2) Enhanced Plus Benefits (tier 3)

Opportunity for the College of Dentistry Potential increase in patients seeking care Student clinics annual procedural requirements for dental students Scaling and Root Planing 640 Root Canals 560 CU/CL 160 RPD 160 FPD 80

Challenge How to train and monitor 300+ providers regarding the unique aspects of the Dental Wellness Plan program Eligibility and tiers of treatment Documentation requirements

Three levels of Providers Faculty Practice (~80) 100% intramural practice Resident Clinics (~50) Advanced training program in all specialties Dental Student Clinics (~240) 80 students per class D2 Clinics Operative (free clinic) and Preventive D3 Clinics Clerkship Model D4 Clinics Comprehensive Care Model Kirkwood Dental Hygiene Program (~24)

Restorations covered If caries extends > 50% of the way to the pulp Written and radiographic/photographic documentation and attachments required Dentures and interim partials covered If provider documents basic human functions that are being restored Root canals covered If comprehensive exam has been done by general dentist

If patient starts treatment before enrolled in Dental Wellness Plan (i.e. cast partial denture) Then becomes enrolled in Dental Wellness Plan prior to insertion We cannot legally bill the patient for the partial denture, and the Dental Wellness Plan will not pay because it is a third tier benefit that the patient has not yet earned

Patients cannot pay out of pocket for treatment that is covered in another tier Restorations of teeth when caries is not encroaching on pulp Can be treated at NC in D2 Operative Patients can pay out of pocket for nevercovered services Bleaching 3 month prophy

Patient can pay out-of-pocket Bleaching Cosmetic Dentistry Replacement of unsightly restorations Diastema closure Implants Be sure to document and inform There is a consent form for never covered benefits

Provider Training (March-April 2014) Mandatory provider training Faculty, Residents, Students, Hygienists, Assistants, Front line staff

Primary education about dental wellness plan benefits occurs at comprehensive exam appointment by provider

Awareness of insurance coverage Familiarity with DWP coverage by tier Clear and specific documentation in patient record Treatment meets specific criteria Appropriate attachments Be aware what tier patient is in before scheduling next appointment Be aware of program limitations

This year (2014) 67,884 Last year (2013) 67,214 + 670 DWP 4,713

Faculty 1,262 26.8% Residents 962 20.4% Predocs 2,489 52.8% Total 4,713 100.0%

2013 2014 Change Visits 174 247 + 73 Procedures 376 433 + 57

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