Dental Benefits and Practice Management: A Guide for Successful Practices

Description

Dental Benefits and Practice Management: A Guide for Successful Practices is a practical tool that helps you manage your office in tune with the realities of modern dental practice.

• Written by both dentists and insurance industry professionals
• Practical explanations to effectively and legally process claims
• Describes the changes in dental practice management to make your practice patient centered
• Competitive strategies for dentists and organizations

Contents

Chapter 1 Why Dental Benefits?
Michael Okuji
Introduction 2
The Coming of Health Insurance 3
Private Health Insurance 7
Moral Hazard 8
Indemnity insurance 10
Benefit service plan 11
Direct service plan 13
Direct reimbursement 14
Health Insurance – The Blues 15
Federal Health Benefits 17
Dental Benefits 20
Dental Service Company 21
What is Dental Insurance? 22
Indemnity insurance 23
Dental benefit plan 23
Preferred Provider Organization 24
Health Maintenance Organization 25
Direct service plan 26
Direct reimbursement plan 27
Discount plan 28
Administrative Services Only 28
Bundled payment 29
Accountable Care Organization 30
Antitrust 31
Conclusion 32

Chapter 2 Dental Benefits – get it done
Michael Okuji
Introduction 2
Dental Benefits 3
Plan design 6
Participating Provider Agreement 7
Credentialing 8
Medicare Opt-In Opt-Out 9
Fees 11
ADA Dental Claim Form (American Dental Association) 11
Dental claim field changes (2012) 13
Dental claim new fields 15
NPI (National Provider Identification) 17
TIN (Tax Identification Number) 18
Narrative attachment 18
EOB (Explanation of Benefits) 21
CDT Code 22
CDT Code Use 23
Categories of service 27
Exclusion and Limitation 29
Limitation 30
Frequency limitation 30
Narrative for exclusion, limitation, frequency 31
Electronic Claim Submission 32
Clearinghouse 32
Electronic attachment 33
Code Maintenance Committee 33
Non-Dentist Provider 35
Diagnosis Code 37
ICD-10 38
Conclusion 40

Chapter 3 Dental Benefits – get it right
Michael Okuji
Introduction 2
Get-it-right 3
Participating Provider Agreement 3
Fees 4
Utilization 5
Utilization review 5
Prospective utilization review 6
Quality assurance audit 7
Appeal and dispute resolution 9
Appeal preparation 10
Termination 11
Summary 12
Dentist and Dental Plan Design 13
Dental Plan Contract 14
Dental Claim Process 15
Benefit eligibility 15
Evidence of coverage 17
Coordination of benefit 17
Non-duplication of benefit 18
Unbundled procedure 19
Balance billing 19
Non-covered service 20
Up-code 21
Deny and Disallow 21
Appeal a claim determination 22
Electronic Services 23
Eligibility 23
Pre-determination 24
Claim submission 25
Electronic funds transfer 25
Claim Filing Tips 26
Desktop Procedures 38
Conclusion.39

Chapter 4 Patient-Centered Practice
David Okuji
Introduction 2
Key to Transform the Health Care System 4
Transformation: Impact on Dentistry 8
Transformation: Evidence in Healthcare and Dentistry 11
Two tier financing 12
Two tier delivery system 13
Accountability 14
Electronic Health Record 15
Population health outcomes 16
Integration of medicine and dentistry 17
Population health outcome 18
Evidence based care 20
Mid-level provider 21
Group practice model 22
Oral Health Care Delivery Model 23
Organizational structure 24
Organizational Structure: Opportunity 27
Integrated medical and dental practice 27
Networked and integrated medical/dental practice 28
Stand-alone networked large group dental practice 29
A Networked solo practice 30
Patient Centered Care: Competitive Advantage 31
Conclusion 36

Chapter 5 Streamline the Practice
Michael Okuji, Dennis Lewis
Introduction 2
Private Practice 4
Systems and operation 4
Electronic eligibility 5
Pre-determination 6
Claim submission 8
Electronic claim submission 8
Electronic direct deposit 9
Electronic dental record 10
Access to the dental record 13
Diagnostic code 15
Airline Analytics 16
Sarrell Dental Center 18
Call center 19
Administration 20
Workforce 20
Community 21
Medical–dental integration 21
Sarrell Dental Center team 22
Quality 23
Social Determinant of Health 25
Patient support system case management 26
Disease management 28
Generational determinant of health 29
Conclusion 30

Chapter 6 Patient Protection and Affordable Care Act
David Okuji, Michael Okuji
Introduction 2
ACA quality 3
Healthcare Insurance Marketplace 4
Public exchange 4
Private exchange 5
Affordable Care Act 6
Title I. Quality, affordable healthcare for all Americans 7
Title II. Role of public programs 7
Title III. Improve quality and efficiency of health care 7
Title IV. Prevention of chronic disease and improve population health 8
Title V. Health care workforce 8
Title VI. Transparency and program integrity 9
Title VII. Improve access to innovative medical therapies 9
Title VIII. Community living assistance service and support 9
Title IX. Revenue offset provision 10
Title X. Strengthen quality, affordable healthcare 10
Key Provisions 10
ACA Essential Health Benefits 12
Medicaid Expansion 13
ACA Funding 13
Drivers of Health Care Reform 14
ACA Quality and Outcome 15
ACA Themes 16
Actuarial Value 18
ACA Dental Benefit 19
Impact on Dentistry 20
Cost of Care 22
ACA Implication for Dentists 23
Pediatric specialist extenders 24
Society’s expectations 26
Conclusion 27

Chapter 7 Ethics and Ethical Behavior
Gary Herman
Introduction 2
What is a Profession? 3
Ethical vs. legal 4
Ethics and professionalism 5
Ethics of quality of care 6
Perceptions of ethics and professionalism 7
Situational Ethics 9
Responsibility to the patient 9
Responsibility to improve health 11
Responsibility to family 12
Dentist as Expert 13
You’re the doctor! 13
Dentist as estimator and advisor 15
Self interest 16
Pattern of practice 17
Ethical practice decisions 18
The importance of profitability 19
Owner versus Employee 20
Employee in a small private practice 20
Employee in large group practice 21
Employee in a public health setting 22
Employees in a dental support organization 23
Dental Board 23
Value of Treatment Alternatives 25
Standard of care 26
Appropriate pattern of practice 26
The wallet biopsy 27
Social Media and Ethical Behavior 28
Will Yelp destroy a practice? 29
Dissemination of fees 30
Future of Dental Ethics 31
What is future ethical behavior? 32
What is quality and who determines? 32
Conclusions 33

Chapter 8 Stay Out of Trouble
Matthew Cassady
Introduction 2
Fraud, Waste, and Abuse 4
Fraud 4
Waste 5
Abuse 7
Bad Behavior 8
Bill for services not rendered 8
Right a wrong 9
Undocumented treatment 10
Unnecessary service 12
Unbundle 14
Up code 14
Kickback 16
Alter date of service 16
Discount 17
Who’s Looking? 19
Fraud, Waste, and Abuse in Your Office 26
How to avoid fraud, waste, and abuse 28
Record retention 33
Conclusion 40

Chapter 9 Analysis to Action
Michael Okuji
Introduction 2
Premise 2
Competition 4
Information 5
Small Private Practice 5
Streamline 8
Group Practice 12
Specialist group practice 13
Permanente Dental Associates 14
Dental group productivity 15
Group Practice System 16
Corporate practice of dentistry 17
Dental support organization 19
Competitive advantage 20
Re-brand 20
Off-brand 21
Integrate vertically 21
Spin-off service 22
New service 22
Partnership 23
Dentist training model 23
Hub & spoke 24
Safety Net System 25
Premise 26
Competitive strategy operations 26
Airline capacity model 27
Competitive strategy partnership 28
Competitive strategy leadership 29
Organized Dentistry 30
Quality 30
Tele-dentistry 32
Integrator Organized Dentistry 34
Group purchasing organization 34
Options for action 34
Integrator Independent Practice Association 37
Integrator Information Technology Company 39
Conclusion 41

Author Information

Michael Okuji, DDS, MPH, MBA, is the Dental Director at Delta Dental of Colorado. Prior to working for Delta Dental, Dr. Okuji maintained a solo private dental practice for 35 years in San Francisco. He was also an Assistant Clinical Professor at the University of Southern California, Ostrow School of Dentistry and a Group Practice Director at the UCLA School of Dentistry. He lectures on insurance issues and practice management. Dr. Okuji is the author of the book Dental Practice: Get in the Game.