At the risk of redundancy for having written about ACA related dental and orthodontic insurance before, I’m doing it again because we now have a bit of good evidence of what is coming with respect to “ACA Compliant” dental/orthodontic insurance policies sold through the Federal and State insurance exchanges.
I forecast in past messages that I believed that under the ACA, traditional dental coverage would be difficult to obtain and that the great majority of dental policies available would be ACA compliant, exchange sourced policies. With such policies pre-authorizations would likely be mandatory. I believed that coverage would be severely restricted to extreme dental/orthodontic problems and that rates of reimbursement would be something close to the low end PPO rates, and perhaps as bad as Medicaid. Those opinions were formed based on an early reading of selected parts of the ACA along with some early opinions voiced by the California Dental Association, an Association that is more progressive than many of the other dental associations.
Take a look at the following letter that has been sent to us, now for the third time, by clients:
Dear Dr.
The Professional Review Department is in receipt of the request for services for the above patient. Our dental consultant requires additional information to complete the evaluation of this case. Please submit the following information within 14 days so we can promptly determine the amount of benefit that we can provide:
The Professional Review Department is in receipt of the request for services for the above patient. Our dental consultant requires additional information to complete the evaluation of this case. Please submit the following information within 14 days so we can promptly determine the amount of benefit that we can provide:
- A completed and signed HLD analysis and narrative describing the nature of the severe physically handicapping malocclusion, along with any documentation relevant to determining the nature and extent of the handicap.
- A panoramic and/or mounted full mouth series of intra-oral X-rays.
- A cephalometric X-ray with teeth in centric occlusion and cephalometric analysis/tracing.
- Photographs of frontal and profile views.
- Intra-oral photographs depicting right and left occlusal relationships as well as an anterior view.
- Maxillary and mandibular occlusal photographs.
- Photos of articulated models can be submitted optionally (Do NOT send stone casts).
- Subjective statements submitted by the provider or others must be substantiated by objective documentation such as photographs, radiographs, credible medical documentation, etc. verifying the nature and extent of the severe physical handicapping malocclusion.
- Requests where there is significant disparity between the subjective documentation (e.g., orthodontic evaluation and narrative) and objective documentation (e.g., photographs and/or X-rays) will be returned for clarification without review.
Sincerely,
Orthodontic Department
LS
Ecs 2240452
Notice the words in the first bullet point…“severe physically handicapping malocclusion…” but also read all of the text listing the “proof” requirements for this ACA compliant insurance policy to cover orthodontic treatment.
Now look at the following document we downloaded from the New York State Medicaid website describing requirements for Medicaid to pay for an orthodontic case:
Handicapping Labio‐Lingual Deviation (HLD) Index Report
(New York State Medicaid Program)All requests for authorization must include:
(New York State Medicaid Program)All requests for authorization must include:
- A completed and signed HLD analysis and narrative describing the nature of the severe physically handicapping malocclusion, along with any documentation relevant to determining the nature and extent of the handicap; and
- A panoramic and/or mounted full mouth series of intra-oral x-rays; and
- A cephalometric x-ray with teeth in centric occlusion and cephalometric analysis/tracing; and
- Photographs of frontal and profile views; and
- Intra-oral photographs depicting right and left occlusal relationships as well as an anterior view; and
- Maxillary and mandibular occlusal photographs; and…
Subjective statements submitted by the provider or others must be substantiated by objective documentation such as photographs, radiographs, credible medical documentation, etc. verifying the nature and extent of the severe physical handicapping malocclusion. Requests where there is significant disparity between the subjective documentation and objective documentation will be returned for clarification without review.
Looks similar doesn’t it? In fact it is almost identical!
I am more than a little suspicious at this point that there is almost no chance that any ACA compliant dental or medical policy (because dental care for persons under age 19 is considered an Essential Health Benefit (EHB) under the ACA some medical policies are already starting to provide dental coverage) is going to cover anything but the most extreme orthodontic problems and then only at a terribly low and an entirely unacceptable fee schedule.
Again, I admit to my redundancy in this article but this issue of reduced numbers of patients with traditional insurance, mandatory pre-authorizations on ACA compliant policies and terrible rates of reimbursement is coming and it is coming fast. Traditional dental/orthodontic insurance is going to become increasingly rare. Given that most orthodontic practices have 40%+ of their case starts with insurance and general dentists and other specialists typically have an insured percentage much greater than that, quality marketing for new patients must be ramped up now. If you are not a natural marketer and/or don’t know how to get motivated, hire a good marketing consultant! Marketing is not a service Z&A provides so there is no hidden motive in that recommendation.
