By Chris Toepke, President, Express Dental & Doctor, a One Call Medical Company
Dental claims in workers compensation? What dental claims?
This response, plus a quizzical look, may be the initial reaction when claims professionals are asked how they handle dental claims. Dental injuries may not be among those that they see most frequently, but these injuries do happen more often than claims managers may realize. And unless these claims are carefully managed, they can delay recovery of the injured worker and add unnecessary costs to the claim. In fact, the average severe workers’ compensation dental claim could require 15 – 20 provider visits to restore the injured worker to pre-injury status. And, some of these claims have been known to top $200,000.
Before concluding that dental claims are rarely seen in workers’ compensation, consider the numerous scenarios that can involve damage to the mouth or jaw:
- Car accidents
- Workplace violence
- Construction and manufacturing accidents
- Slips and falls
In general, many injuries which involve body parts from the neck up will likely include some type of dental-related injury.
Occupations that make up a significant number of workers’ compensation dental injuries include manufacturing related and other trades, which account for about 10 percent of dental injuries, and police and correctional officers, including firefighters, which account for about seven percent. Teachers, medical professionals, truck drivers and delivery people are three categories that each constitute about five percent of dental claims.
In addition to workplace accidents, the experience of pain itself can cause a problem with the jaw or mouth. For example, frequent teeth gnashing or grinding is a cause of TMJ (temporomandibular joint) disorders. TMJ problems, which can also be caused by an injury itself, are particularly problematic and expensive, because they can require extensive reconstruction and are subject to easy re-injury.
There are three reasons why dental claims are particularly challenging for the claims manager.
- Multiple provider visits. Unlike most workers’ compensation services such as MRIs and X-rays, which are only required once or twice during the course of the claim, dental work may require multiple visits over time to different types of providers. Managing those visits can become time consuming and distracting
- Infrequent occurrence. Because dental claims are uncommon and tend to be complex, there can be a lack of protocols and guidance on how to manage them
- Prevalence of overtreatment. Overtreatment can easily occur, especially if the injured worker has not received regular dental care. In these cases, the dentist may treat problems throughout the entire mouth, not just the injury
Here are some of the most frequent issues claims professionals face in managing dental claims, and advice on how to address and resolve each one:
Finding the right dentist: Or even any dentist who can handle a work-related injury. Until recently, dental networks for workers’ compensation did not exist. Most dentists are still not familiar with workers’ compensation and do not accept workers’ compensation patients. One major reason for their reluctance is a lack of understanding about how they will receive payment. They are also wary of the administrative costs of completing the unfamiliar paperwork required by the state.
This problem can be resolved by working with a resource that has a network of credentialed dentists throughout the United States, so that a qualified provider who understands workers’ compensation injuries, documentation and billing is conveniently located to the injured worker. This resource should further support the dentist in managing the workers’ compensation case by providing him or her with a packet that includes instructions to perform an oral evaluation of the mouth, the proper forms to complete, and guidelines for them to treat only the injury and not non-injury-related conditions.
Once dentists understand the system and have the benefit of this education, they are more willing to accept workers’ compensation referrals, especially if there is a likelihood the injured worker will become a regular patient.
Selecting the right dental specialist: Does the injury require a periodontist, an endodontist, an oral maxillofacial surgeon or all three? What about a general dentist or prosthodontist? There are a number of specialties in the dental profession, and it can be challenging to determine just what type of specialized care the injury may require. It is important to tap the expertise of a clinician, or claims professional with dental knowledge, to help navigate the universe of specialists and select the appropriate provider for each individual case.
Obtaining the right level of clinical support and advice: based on the injury and potential comorbidities of the patient. Dental claims range from simple to highly complex. Many implant cases in particular require surgeries and significant healing time, as well as considerable clinical oversight. Sometimes dental care is required to heal an infection in the mouth before a surgery can be performed. Or, the patient may have other conditions that complicate or delay dental treatment, such as blood thinners, anesthesia complications, diabetes, smoking, osteoarthritis.
Expert clinical resources can focus on particular types and levels of dental claim complexity. For example, “medical only” claims such as chipped teeth or resin composite fillings are typically handled in one-two dental visits. If the treatment plan is more complicated and two or more providers are on the file, additional oversight and coordination is required. These claims usually involve claims from an oral surgeon or endodontist and are open from two-three months or more.
Assistance with complex cases: The most complex types of dental claims are TMJ cases and implants. These claims are usually open six to 18 months or more. These claims requires experts who have years of specialized experience with these treatment in order to find and manage the right, highly qualified, specialists in convenient locations for the injured workers.
Getting the worker to the right specialist, at the right time: Just as with other services, the dental claim is expedited when injured workers gets prompt access to the right provider needed at each stage in their recovery. However, given the infrequency with which many claims professionals deal with dental claims, this can be difficult. They may not have access to providers in close proximity to the injured worker, or have at their fingertips the appropriate specialist that might be needed. Here, again, specialized resources can be brought into the case to expedite fast treatment by the right provider.
The timing of treatment can also be a question that needs resolution. For example, sometimes dental injuries must be treated immediately. In other situations, other injuries require the highest priority, and the dental problems may be addressed after major injuries have healed. In these instances, close coordination of services are required throughout the continuum of care.
Setting Reserves: Just as with other workers’ compensation claims, appropriate reserves must be set for dental injuries, based on the estimation of the services that will be needed through the life of the claim. This determination can be complicated because, as noted, multiple services can be needed from various specialists to repair dental injuries over a long period of time. In developing the plan of treatment it is important to assess the need for all services and their costs so that appropriate reserve funds can be set aside.
In conclusion, dental claims occur with more frequency than most workers’ compensation claims professionals realize. With specialized handling, these claims can be managed to a successful outcome and at a lower overall claims cost.
About Chris Toepke
Chris Toepke is the President of Express Dental & Doctor (Express), the first and only national dental program to address the specific needs of the workers’ compensation, auto, and liability industries, and a subsidiary of One Call Medical, Inc. (OCM).
Express is focused on delivering significant administrative and clinical value to adjusters and payers as it relates to all aspects of the dental claims management process. In addition, Express offers the unique ability to manage referrals for other hard-to-find medical providers in such areas as hearing, eye, and specialty medicine.
Toepke previously served as Vice President of Product Development at OCM. Prior to joining OCM, he was a management consultant with Bain & Company. He holds an MBA from the Kellogg School of Management at Northwestern University and a BA from Lafayette College.
About One Call Medical
One Call Medical (OCM), the nation’s leading provider of specialty services to the insurance industry, has a “smart partner” approach in delivering its suite of easy-to-use, efficient, and cost-effective ancillary services that help claims professionals to achieve superior outcomes. OCM enables injured claimants and insurance payers to get the best quality and value for diagnostic scans and electrodiagnostic testing—the building blocks for successful treatment plans and optimal return-to-work results. Through its STOPS subsidiary, the company provides transportation and language services, required by today’s increasingly diverse claimant population; and through its Express Dental Care subsidiary, OCM assists with all aspects of the dental claims management process, as well as handling referrals to hearing, eye, and other hard-to-find specialty providers. OCM’s customers include the nation’s leading insurance companies, third-party administrators, payers, and self-insured employers. More information about One Call Medical can be found at www.onecallmedical.com.