October 2003 Newsletter

---

Receive this newsletter electronically

---

Save the Date:
April 14, 2004
All Day Course with Dr. Vince Kokich

---

Spotlight on Dental Benefits (from NJDA)

Q: What are the time requirements for payment of insurance claims?
A: With the exception of Personal Injury Protection (PIP) and Workers’ Compensation claims, carriers (including various types of managed care plans) must pay “clean” claims within 30 days (for electronic claims), 40 days (for paper claims), or in the case of capitation payments, within 5 days of the due date. Overdue payments must include simple interest at the rate of 10% per year. However, certain self-insured plans and union trust funds governed by ERISA are not subject to state regulation.
Q: An insurance company is requesting a refund for a claim it states was paid in error. Must I comply?
A: Absent a specific contractual agreement related to this issue between a dentist and a third party payer, it is widely held that an insurance carrier is not entitled to recover an “overpayment” made to an innocent third-party creditor (e.g., dentist) when: (1) the payment was made due solely to the insurer’s mistake; (2) the mistake was not induced by a misrepresentation of the third-party creditor; (3) the third party creditor acted in good faith without prior knowledge of this mistake; and, (4) the amount is not greater than the sum that was owed to the third party creditor. If you receive such a request, contact NJDA for assistance.
Q: When can a claim be submitted for a multi-visit procedure, such as endodontic or prosthetic procedures?
A: The short answer is that, if prominent disclosure is provided on the form, a dentist may legally submit a claim at the beginning of treatment. But dentists would be prudent to consider the long answer which follows before making a decision.
State Board of Dentistry regulations (N.J.A.C. 13:30-8.10) prohibit a licensee from submitting a claim that contains “any description of a dental service or procedure which does not accurately reflect the actual work completed.” A dentist may submit a claim following initial treatment as long as the actual status of treatment is accurately and non-deceptively disclosed on the form to avoid allegations of fraudulent billing. Dentists who use older versions of the ADA Standard Claim Form should also alter the dentist’s certification statement. (The Version 2000 ADA Claim Form no longer requires dentists to certify that the submitted procedures have been completed; the new certification now states “I hereby certify that the procedures as indicated by date are in progress (for procedures that require multiple visits) or have been completed”.) However, dentists should be alert to the fact that some plans “incur liability” when a procedure begins, but others don’t consider their liability to incur until a procedure is complete. This is especially significant at the end of a calendar year or if a patient loses coverage in the middle of treatment. Further, some plan participation agreements specifically state that a dentist may not submit claims until the procedure is complete.
Q: An insurance company is requesting a radiograph before it will pay my claim. Must I comply?
A: If the requested radiographs are available, dentists should submit diagnostic copies (never the original). However, if radiographs were not necessary for diagnosis or treatment and, therefore, not taken, the carrier cannot withhold payment solely on the basis that radiographs did not accompany the claim. State law (N.J.S.A. 45:6-18.2) provides that radiographs may be used in the course of dental services only for diagnostic or treatment purposes, not to verify the performance of dental services.
Q: I do not accept insurance assignment in my office, but I do complete the claim form for the patient. May I charge for this service?
A: No. State law (N.J.S.A. 45:6-18.1) prohibits dentists from charging for the completion of claim forms. However, no law or regulation prevents dentists from charging a fee for the completion of pre-authorizations submitted at the patient’s request.
Q: If plans cover crowns, why do they deny claims for crowns placed on implants?
A: Coverage for implant crowns is largely decided by the language contained in the plan’s master policy document. Most dental plans exclude implants and anything attached to them. However, some plans cover implants as well as the attached prosthetics, while others exclude implant surgery but do provide some alternate benefit for the crown or prosthetic. Always pre-authorize any type of implant-related service.
Q: I received payment from my patient’s dental plan based upon the plan’s determination of UCR, which is considerably less than my actual fee. There is a statement on the check that the payment is considered “payment in full”. Is this binding or may I deposit the check and bill the patient for the balance?
A: This type of restriction is enforceable so, if you accept the check, you accept the payment as “payment in full”. Some self-insured plans adopted this technique to hold down their costs but prevent them from being passed on to their employees. This also occurs when an insurance company is impaired or becomes insolvent and payments are made from the “Insurance Guaranty Association”. The law which created the association requires a “provider of health care services”, in order to receive payment, to forgive 20% of the obligation which would otherwise be paid by the insurer had it not been insolvent.
Q: How can I legally waive the copayment for certain patients (e.g., clergy)?
A: A dentist must “conspicuously disclose” on the face of the claim form that all or a portion of the copayment will not be collected from the patient. Based on information reported to NJDA, it appears that the result of this disclosure may be that the plan will reduce its payment accordingly. For example, if the plan normally covers 80% of the fee, but a dentist indicates that the 20% copayment will not be collected, the plan may only pay 80% of the amount that the dentist intends to collect (80% of 80%).
Q: I have a problem with a plan that my office has not been able to resolve. What is my recourse?
A. Member dentists can always turn to NJDA’s Claim Resolution Program (CRP) for assistance with a variety of non-payment issues. NJDA has been very successful in resolving problems. In 1999, NJDA received a total 140 complaints; of this number, only 10 were not resolvable because of a specific policy limitation not previously communicated. Twenty-three complaints were submitted for “data purposes only” after the dental office resolved the problem; this information is helpful in alerting NJDA to patterns of poor performance of the part of specific plans. Contact NJDA’s Department of Dental Care Programs for a copy of the CRP form.

---

Are You Ready For October 16?
October 16 is the deadline for HIPAA standard electronic transactions and code sets. Are you ready? If your dental practice management system vendor isn’t ready, neither are you. The testing for the standards began in April but not all software vendors and clearinghouses have completed that testing. Payers (insurance companies) must be ready to accept all HIPAA standard transactions by the October 16 deadline also.
Within these new standards is a new ADA claim form. This form requires more information than what you are accustomed with the old form. If you submit insufficient data on the new form your claim will be rejected. The other critical item is that you must use CDT-4 codes. You can obtain these codes from your software vendor or the ADA.
Review the HIPAA Privacy Kit you received at the NJDA meeting last year. Call your software vendor and clearinghouse with any concerns or questions.
Respectfully submitted,
Mark A. Vitale, DMD

---

The Council met on September 10, 2003.
• CRP statistics were reviewed. The largest number of complaints was against MetLife.
• Two issues involving MetLife were discussed. The first involves MetLife’s bundling of the examination with perio maintenance. This is contradictory to the HIPAA compliant CDT-4 code D4910, which does not include the exam. MetLife has been denying the exam and leading the patient to believe that the dentist billed inappropriately.
The second issue relates to MetLife’s calculation of UCR for non-par dentists. If a dentist submits claims after increasing fees, he/she will be reimbursed on the basis of the old fee until MetLife’s next quarterly update, and then future claims will be paid at the new “usual” charge. If a dentist does not bill MetLife routinely, then the amount paid will be based on fees that are years old. NJDA is working to resolve these issues.
• Delta requires that a dentist file their usual or most frequently charged fee for primary and permanent restorations D2140-D2161. CDT-4 does not distinguish between primary and permanent, therefore only one set of fees is permitted.
• The council discussed the new HIPAA compliant ADA insurance form which must be used starting October 16, 2003. This form requires much more data than the previous form.
• Direct reimbursement plans were reviewed.
• Horizon Dental is starting a pilot program in child identification. With over one million children missing each year, the CHIP program is currently the most comprehensive identification program available to collect necessary and accurate information to locate missing children.
• The ADA and Aetna reached an agreement to settle a class action suit the Association filed two years ago. The agreement requires Aetna to improve the fairness and speed of claims processing, and reduce administrative burdens on dental offices. Also one million dollars is to be paid to the ADA Foundation and four million dollars to the class member dentists. The ADA News and website have details about this settlement.
• The prompt payment bill was reviewed. Insurance companies must acknowledge receipt of claims, and they must request x-rays and documentation via fax or phone.
• Delta is expanding its dental plan for AARP in Texas, Maryland, DC, Alabama, and Pennsylvania.

---

NJDA NOTEWORTHY NEWS

NJDA Noteworthy News
REPORT OF BOARD COMMITTEES
Budget Hearing Committee
Dr. Jeffrey Rempell reported that the Budget Hearing Committee approved as presented and recommended the adoption of the 2004 Proposed Budget. There being no changes in the proposed Budget, a motion was made, seconded and unanimously approved.
REPORT OF TASK FORCES
Task Force on Amalgam & Waste Water
Dr. Robert Giantomas, Chair, reported that he had received a communication from Washington State. The Department of Environmental Protection reached an agreement with the Washington State Dental Association. There will be no in-office testing. Instead, dental offices are to use Best Management Practices (developed by the ADA) along with the installation of amalgam separators.
Dr. Giantomas urged our members to follow these Best Management Practices to demonstrate to the New Jersey Department of Environmental Protection that we are doing something about this problem. Dr. Giantomas reminded the members that he is still looking for additional people to serve on this Task Force.
REPORT OF COUNCILS
Council on Annual Session Ms. Ricky Dibofsky
Some Board members questioned the feasibility of continuing with the Circus, as revenues have not covered expenses for a few years. Ms. Dibofsky reported that she is looking into the Liberty Science Center as an alternative and will contact members of the Hudson component who have past experience working with the Liberty Science Center.
Council on Dental Benefit Programs Ms. Mary Moskal
Reported that the Department of Banking and Insurance adopted the regulation on the elimination of extrapolation with five exceptions. One of those exceptions is if there is clear evidence of fraud. If it is felt that the carriers are abusing the exceptions, the exceptions will be looked at again by the Department of Banking and Insurance.
Mr. Arthur Meisel added that the dental decision regulation appeal is fully briefed. It should be scheduled for oral argument sometime this fall.
Ms. Moskal reported on the process that Met-Life uses for payment to non-participating doctors. The first fee you charge is locked in their computer. You must notify them by letter of any increase in your fee to receive a higher reimbursement.
Council on Governmental Affairs Jim Schulz
Trenton is on recess until November. Dr. Rempell applauded Jim Schulz, Mary Moskal and Eric Elmore on getting the adult dental Medicaid fully restored and reported that many letters of appreciation were received.
Mr. Schulz reported the Collection of Benefits bill should be done in November. During summer recess he has met with some of the regulatory people. A regulation proposal by the Health & Senior Services on safety sharps and needles is under review.
Council on Communications Eric Elmore
Reported that the new NJDA Website is now up and operational, however, we are still updating and making changes. Over the next two or three weeks, you will see old and new information disappearing and re-appearing. We are exploring with NJNTV the possibility of running 1,2 or 3 minutes shorts at various times. This will cover the entire state and enable us to get messages out quickly. We are studying the costs involved
Council on Membership Trish DeCotiis
Council on Membership is striving to establish a relationship with the students at UMDNJ Dental School. We will be sponsoring a social event at UMDNJ on August 19th for freshman orientation and Dr. Rempell will be speaking to them earlier that day. On September 5th we will be meeting with Dr. Fenesy, the student leaders, deans and assistant deans to create open discussion on what we can do for them.
NJDA has two dates for CE courses, September 10th and October 1st. Registration has begun. Ms. DeCotiis requested that the trustees have their component program chairs get in touch with Eric Elmore with the dates of its component CE courses so that we do not duplicate dates. Also the weekend study clubs will start in September at the Association headquarters and all speakers are NJDA members. These continuing education programs are open to members only.
Last but not least, Ms. DeCotiis discussed the findings of the Sub-committee on Component Border Towns. Due to concerns of the NJDA Staff and members as well as non or new members that the present allocation system needed review, particularly in the various border areas, a discussion was necessary. The Sub-committee recommends that the Bylaws of the Board of Trustees be amended by deleting the requirement that a member must be maintained in the component society in whose jurisdiction the main office of the dentist is registered with the State Board of Dentistry. A list of border towns with new assignments was distributed to the Board members. This is being done in an attempt to give NJDA staff the information it needs for placement of new members. After considerable discussion, it was felt that new members in these border areas should be able to go wherever it is most convenient for them. If it is more convenient for them to belong to a component society nearer their home or on a more convenient evening, they should be able to choose. This is also true for an active member who may find it more convenient to belong to another society because of logistics. Dr. Chinoy reminded the Board members that if a Bylaws change were to be brought to the November House meeting, the resolution should be presented to the Board of Trustees no later than the September 24, 2003.
PRESIDENT’S REPORT – Dr. Jeffrey H. Rempell
Dr. Jeffrey Rempell reported that he attended two conferences at the ADA in Chicago, the President-Elect’s Conference in January and the Leadership/ President’s Conference in July. He reiterated how good the meetings are and how much the staff in Chicago appreciates Jim Bramson and how it reflects in the work they perform. He reported there is considerable discussion on the lack of access to care and that states are experiencing and the lack of dentists. He sat in on an interesting presentation from one of the speakers, Shelia Thorn, on diversity issues. She stressed the importance for societies to have a more diverse representation.
VICE PRESIDENT’S REPORT – Dr. August Pellegrini
Dr. Augie Pellegrini reported that he will meet with Dr. Feldman to begin the recruitment of non-member faculty. We have already received the list of all UMDNJ faculty at the school. He is working with Trish DeCotiis on a recruitment letter to the faculty through the Department Chairpersons. Dr. Fred Sterritt requested that his name be on the letter to the UMDNJ faculty. Dr. Pellegrini plans to ask Dr. Feldman if we can make a presentation on recruitment at an all faculty meeting held at the school. He reported that they will also be discussing the issue of foreign-trained faculty with Dr. Feldman.
TREASURER’S REPORT – Dr. Robert Hersh
Except for some outstanding disputed charges at the Taj Mahal, it appears that we have made a $21,000 profit from the Annual Session Conference this year. He reported that dues payment to date is substantially ahead of last year at this time.
EXECUTIVE DIRECTOR’S AND LEGAL COUNSEL’S REPORT – Mr. Meisel
Mr. Arthur Meisel reported he receives a membership grid weekly on what members have paid in dues to date. He very happily reported that we are ahead 309 paid in full members compared to last year at the same time. We are moving in a very positive direction.
Mr. Meisel mentioned that we received a Direct Reimbursement questionnaire from Pennsylvania. Pennsylvania is the second most successful state in implementing direct reimbursement. It subsidizes DR with a $250,000 infusion each year to keep the program going. It will be very interesting to see how this plays out if Pennsylvania pulls out.
Mr. Meisel remarked about Dr. Rempell’s discussion on the diversity issue on membership. The Board agreed to focus on that issue at the Board retreat in November.
UNFINISHED BUSINESS
Dr. Robert Shekitka reported that the last meeting was a fact-finding meeting. Dr. Shelia Dashkow, Chair of the NJ Dental I.D. Team, is writing a mission statement and policy manual. They are creating specific pathways to membership, working together on funding requirements going into the future, training, etc. It was requested that prior to September 2003, that the Task Force present a time frame and agenda to the Board.
NEW BUSINESS
The discussion held under the Council on Membership regarding a new endorsed program for a merchant card service was carried over to New Business.

---

Answers to Last Month's Crossword Puzzle

LOCAL•BLOCKPARTY•
ARLIS•E•••PISA•OR
DEARDIARY••NIP•DO
Y•S••D•ME•A•SIXAT
D•PEDOINASPEEDO•A
I••AULD•TCB•ES•ET
AMEND•••IR•R••••I
S••DE•LIMAPERU••O
TOPICALDEPRESSION
END•AM•L••OFTEN••
MOLARICECAPS•ETCH
A••P•N•••D•••PE•O
•C•ER•STREP•DIRTY
•HEXINTHECITY•FIT
BIS•NARAS•TILTED•
ALP•STATIC•VANR••
DDE•EXPANSIONTEAM

---

October Issue Spotlight:
Dental Benefits




Personal & Confidential
(Name & Address of Carrier)

RE: (Insured/Patient Name)

(Insured ID#)

Dear
This letter is to notify you that the claim submitted on behalf of the above -referenced patient is overdue and I am requesting immediate payment along with the appropriate interest.
New Jersey law and subsequent regulations (N.J.A.C.11:22-1) require that health/dental claims be paid within 30 calendar days if submitted electronically, or 40 days if a paper claim is submitted. If a carrier intends to dispute or deny a claim, the carrier must notify the patient’s practitioner (if benefits are assigned) within the 30 or 40 day period of all of the additional information that is required in order to allow for processing. If those requirements are not met, the plan waives its right to deny or dispute the claim, the claim is deemed to be “overdue”, and is subject to a simple interest penalty at the rate of 10% per annum, which must be included in the claims payment or sent by separate check within 14 days.
The New Jersey Dental Association (NJDA), a professional association of over 4,000 actively-practicing New Jersey dentists of which I am a member, is monitoring the extent to which dentists continue to be plagued with third party payment problems in order to provide input and documentation to the New Jersey Department of Banking and Insurance. Therefore, a copy of this letter is being sent to NJDA.
Sincerely,

C: NJDA Department of Dental Care Programs