With prescription drugs and paramedical benefits taking up an increasingly large portion of employers’ benefits spend, dental benefits often avoid the spotlight. But consultants and insurers are emphasizing a few dental issues for plan sponsors to consider in 2020.
Though GE Canada isn’t focusing on dental benefits in this year’s renewal process, Diana McNiven, the company’s manager of compensation and benefits, highlights the need for research-defined guidelines around dentists’ billing practices.
“Preventative dental and basic dental techniques are not something that there’s a lot of administrative guidelines around, and so [sometimes] the first question a dentist asks you is, ‘What’s your coverage?’ Not every dentist [bills] to the max, but some do, and so we’re spending a lot on dental that we probably don’t need to be.”
For example, most of GE Canada’s plans have a maximum number of units of scaling — a procedure that involves cleaning below the gum line to remove any plaque buildup — that plan members can use per visit or per year. McNiven is concerned plan members who only need a light level of scaling are, in some cases, being given — and charged for — the maximum amount of units each visit. “We don’t want to deter people from having the preventative measures that they need, but we also don’t all need an X-ray every year, 12 units of scaling, etc.”
Currently, plan sponsors are unable to determine how much of their dental spend is due to over-billing. Joan Weir, director of health and disability policy at the Canadian Life and Health Insurance Association, says insurers are also concerned about dentists billing to the maximum. However, since they don’t yet have their own research on what constitutes necessary or acceptable service, insurers rely on resources from dental colleges instead.
In terms of over-billing, Weir says the insurance industry is concerned about dentists performing excess amounts of scaling, conducting an examination every time a patient comes in even when it isn’t necessary and billing for the more difficult types of tooth extraction when a simpler — and cheaper — extraction is appropriate.
However, insurers do have levers they can pull. Ned Pojskic, pharmacy and health provider relations leader at Green Shield Canada, says claim adjudicators are able to assess the appropriateness of dental claims by reviewing patients’ previous claims and “virtual tooth history,” which contains information on things like which teeth have fillings and if a patient has had a surface restoration.
As well, plan design features such as requiring prior authorization for more difficult tooth extractions and X-ray examinations to determine the difficulty of a procedure can guard against over-billing. If insurers suspect providers are over-billing, they can also contact plan members to ensure they received a particular service.
“There are controls around a lot of that today that would make a dentist who is billing to the max pretty evident,” says Weir. “So either some claims would start to be denied or that dentist would be red-flagged for an audit.”
In a statement to Benefits Canada, Zelda Burt, communications manager at the Canadian Dental Association, said dentists who choose to help their patients use all of their available dental benefits in a given year have to be careful not to misrepresent the fees charged or the services provided, since that would constitute insurance fraud.
“When CDA discusses the process of submitting dental benefits claims with provincial dental associations whose members are dentists, CDA underscores that a dentist’s role is to provide accurate information about services provided and/or fees charged to patients.”
This conversation highlights a larger debate in the industry. “There are some real questions around the evidence base supporting the various practices which are now taken for granted,” says Pojskic.
For instance, take the established wisdom that receiving a cleaning every six months is an important part of oral health care. “Emerging evidence . . . showed that adults who have no oral health disease in the mouth who received a cleaning and those who did not receive a cleaning were no different in terms of outcomes several years later,” he says. “For healthy adults, dental cleanings may not even be necessary. It’s a different story when you have some kind of periodontitis or other type of disease — then cleanings are a necessary part of oral health care.”
Green Shield Canada is currently partnering with the University of Toronto’s faculty of dentistry on a long-term study to address this question. The study will make dental services available to uninsured people, while studying the value of certain services and procedures. “The partnership is going to be a key part of how we’re trying to generate the evidence necessary around the appropriateness of care in the dental world,” says Pojskic.
Fee guide increases
For plan sponsors with employees in Alberta, it’s important to be mindful of the large increase in suggested dental fees in the province and how it may affect costs in 2020.
In December 2019, the Alberta Dental Association and College released its 2020 fee guide with a suggested average increase of 4.4 per cent, citing the need to keep up with rising costs. By comparison, its 2019 fee guide suggested no increase. While the average increase for 2020 appears large, actual fee increases vary across different types of services.
Alberta’s recommended increase comes a year after the Ontario Dental Association suggested an average 4.19 per cent fee increase, which the association said was due to updates to infection prevention and control standards. In comparison, the association’s average yearly rise over the past decade was around two per cent. This year, Ontario plan sponsors will see some relief, with the association suggesting an increase of just 1.27 per cent.
“We’re glad to see [Ontario’s] trend go down, but we did see Alberta pop up . . . for 2020,” says Weir. “Considering the economic situation in Alberta, that’s going to be a tough price increase for Albertans and Alberta employers to manage.”
Before reacting to fee increases, plan sponsors should review their year-over-year costs to see if they are actually rising, says Dave Patriarche, president of Mainstay Insurance Brokerage Inc. “You should be looking at the numbers to see where they’re going, not just because of the fee guide. This is just one thing to look at. I would never suggest cutting your coverage because the fee guide went up, or [switching] over to last year’s fee guide. It just delays the problem.”
As disruptive technologies affect other parts of the benefits plan, they may also be set to shake up dental.
Insurers have started to see 3D printing used in orthotics and other types of benefits supplies, says Weir, and it’s coming to the dental space too. For example, one use is for building crowns right in a dentist’s office. “Having to send something out to a laboratory is going to incur the laboratory’s time and resources to make something, so if you can do it chair-side . . . it can be done in a shorter timeframe, maybe with the patient lying right there, and you don’t have that expense of sending it out.”
Pojskic is also watching the startup community for innovations, like SmileDirectClub’s direct-to-consumer model for clear aligners. The teledentistry company provides customers with a virtual assessment from a dentist and the aligner comes at a discounted price compared to regular orthodontic treatment. “That’s a very interesting trend that has the potential for massive disruption of . . . orthodontics. The procedures are getting simplified, the technology is getting better and the . . . technology is being delivered remotely, [by direct mail] in many cases.”
Currently, insurers don’t cover direct-to-consumer dental products, but a number are looking into it. “This is a next wave that will take place whether we like it or not,” says Pojskic. “It’s definitely a trend that will be very prevalent in 2020 and going forward.”
Kelsey Rolfe is an associate editor at Benefits Canada.