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- January 10, 2006 -
Attendance: Ashmen, Brunsden, Courey, Fahsbender, Fertig, Galkin, Glickman, Kahn, Lawson, Leizer, Mirmadjless, Nandra, Prabu, Savage, Schambra, Silverstein, Simos, Villa, Vitale, Wasserman, Weiner, Ziemba
Acceptance of Minutes-vote unanimous.
President’s Report-Stephen Lawson
Welcome to Dr. Nima Mir Madjlessi, Dr. Arpan Nandra and Dr. Tara Savage to the MCDS Board of Trustees Meeting.
The State of New Jersey, Department of the Treasury, Division of Revenue now requires Middlesex County Dental Society to use the electronic format to file and pay our annual report. The payment for $25 was made by credit card. The names and addresses for the officers are required annually. Non-profits must provide at least three names. Updated officer information was provided (S. Lawson, R. Silverstein, and J. Courey).
The Task Force on Prevention, Early Detection and Treatment of Cancer in NJ is asking for one or two component members to be dentist volunteers. The volunteers would serve as a liaison between the County Cancer Coalition and MCDS. No prior experience is necessary, only a strong desire to help. Contact Dr. David Lederman at 732-901-7575.
NJDA is requesting nominations for Trustees, ADA Delegates, Council Representatives and Delegates and Alternate Delegates to the NJDA House of Delegates. Nominees were contacted to confirm their interest in the positions.
I will be attending the Council on Nominations Meeting on January 25, 2006. Dr Richard Kahn, a MCDS member, is a nominee for NJDA Treasurer.
Life Member biographies were faxed to the NJDA President, Dr. August Pellegrini.
I want to thank Dr. Bob Silverstein for creating the MCDS Board of Trustees on-line discussion group.
Secretary’s Report-Mark Vitale
Nominations for council positions were discussed and acted upon. The following individuals were nominated:
ADA Delegate -Dr. Leizer, ADA Alt Delegate-Dr. Clemente, State Trustee-Dr. Kahn, Alt Trustee- Dr. Villa, Annual Session-Dr. Ziemba, Dental Benefits-Dr. Vitale, Dental Education-Dr. Ashmen, Governmental Affairs-Dr. Weiner, Membership-Dr. Galkin, Peer Review-Dr. Fahsbender, Relief-Dr. Glickman, Judicial-Dr. Fertig, NJDA Delegates-Drs. Brunsden, Courey, DeSciscio, Kahn, Krantz, Lawson(chair), Leizer, McLaughlin, Rosenheck, Silverstein, Villa, Vitale, Galkin, Prabu, Ashmen, Alt Delegates-Fertig, Glickman, Ibrahim, Rosen, Schambra, Simos, Wasserman, Weiner, Ziemba, Savage, Mirmadjless, Nandra
Treasurer’s Report-James Courey
See full report on page 3
Editor’s Report-Mitch Weiner, Bob Silverstein
This month I created a Google Group for the MCDS Board of Trustees, so that we could discuss issues and post reports between Board meetings. Board members who would like access to the group can request to be included by following the link available from the Board of Trustees link on our web site.
Program Chairperson’s Report-Scott Galkin
The Cowie course in November had a good turnout, despite an initial slow course sign-up. We had 43 doctors and 14 staff in attendance. All of the vendors were happy with the time they had to meet with the course attendees. Dr. David Garber will be presenting a full day course on Wednesday, April, 19, 2006 at the Pines. We already have 50 doctors and 10 staff enrolled. A postcard was sent, after New Years, to all dentists in the state promoting the course.
Give Kids a Smile-Cavan Brunsden
February 3, 2006 A day of volunteer dentists and staff giving free care to
children in need including over 300 dental chairs, 600 dentists, 100 statewide sites. Over 3000 children are expected to be seen. This program highlights the access to care issue for children in need; NJDA and UMDNJ working together.
NJDA Council Reports:
Children’s Dental Health Month- Cavan Brunsden
The poster contest is underway for children’s dental health month.
Dental Benefits-Mark Vitale
See report on page 4.
Membership-Scott Galkin
The membership council will meet on Thursday, January 12, 2006. We will also be having a membership subcommittee meeting on Wednesday, January 25, 2006 at the home of Dr. Ethan Glickman, to discuss things that we can do locally to help increase membership.
Peer Review-John Fahsbender, Mark Vitale
Two cases were reviewed in the last three months. All three were resolved in mediation with the patients receiving refunds.
Relief-Ethan Glickman
Dr. Glickman explained the purpose of the Council on Relief. Dr. Vitale suggested that a protocol be established to assist members who suffer a hardship with their practice such as an office fire or flood. Dr. Glickman will bring this back to the council for discussion.
Committee Reports:
Corporate Sponsorship-Constantine Simos
We are working with Total Care regarding the sponsorship of Dr. Molinari’s lecture. They will finalize their plans this week. Also Smith Barney Financial would like to continue sponsoring the society. They will sponsor Dr. Glick’s lecture and are interested in providing our membership some additional information by mail.
New Business
-The nominating committee submitted the following slate of officers for next year. Following discussion the following were approved.
President- Dr. Silverstein, President-Elect- Dr. Courey, Vice-President- Dr.Vitale, Treasurer-Dr. Galkin, Secretary-Dr. Prabu, Program Chair-Dr. Ashmen
-The Board voted to update the salary of the executive secretary.
-Motion by Dr. Silverstein, seconded by Dr. Weiner and approved: Amend the ByLaws: Article IV, Section 7: To be inserted after the first sentence: If the Acting President is to serve more than 6 months of continuous service before the next scheduled election, he or she will be entitled to be called “President” for all purposes related to this Dental Society, including, but not limited to, historical records. This change in title is to be made effective as of the date that the office of President becomes vacant. If this change passes, it shall be retroactive to September 13, 2005. This motion now needs to be presented to the membership at the February meeting and must be approved by a 2/3 vote of the members in good standing present. (You can read the By-Laws under the Archives section of our web site).
-Motion by Dr. Silverstein, seconded by Dr. Weiner and approved: That “Life Members” may invite guests to the January general meeting during which they are presented with Life Membership. MCDS will pay the cost of dinner for up to 4 guests per Life member.
Respectfully Submitted,
Mark A. Vitale, DMD
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(11/1/05-12/31/05)
Checking 23,190.98 4,845.74
Savings 58,461.88 23,619.67
9 month CD --- 45,000.00
TOTAL 81,652.86 73,465.41
P&L STATEMENT CHECKING ACCOUNT
(11/1/05-12/31/05)
INCOME
Cont. Educ. Inc 1,960.00
Corp Spon C.Ed. 390.00
Corp Spon Mentor -110.00
Corp Spon Mtngs 1,000.00
Corp Spon Newsl 1,440.00
Dues 300.00
Interest 7.93
Mentor Comm Inc 2,400.00
Total Income 7,387.93
EXPENSES
Cont. Educ. Exp 6,908.71
Dinner meetings 2,841.88
Exec Comm Dinner 266.92
Executive Secretary 1,420.00
Memorials and Gifts 27.55
Mentor Comm Exp 3,505.94
Name Badges 82.26
Office Supplies 504.53
Secretarial 100.00
Telephone 75.38
Total Expenses 15,733.17
OVERALL TOTAL (8,187.45)
P&L SAVINGS ACCOUNT
(11/1/05-12/31/05)
INCOME
Interest 157.79
TOTAL INCOME 157.79
EXPENSES
TOTAL EXPENSES 0.00
OVERALL TOTAL 157.79
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In Memoriam
Dr. Marvin Greenwald.
Dr. Greenwald practiced dentistry in Carteret for 57 years. A pioneer in cosmetic bonding, he designed the first free standing specialized dental office in New Jersey.
Dental Specialist seeks office space in previously existing office (with or without equipment) or in exisiting office in either East Brunswick or New Brunswick.
Please contact Dr. Blume at
732-995-2496 or
[email protected]
CRP Statistics was reviewed from January 1, 2005 through October 31, 2005. There were 112 complaints submitted to NJDA; 51 were resolved, 18 were for data purposes, 33 are pending, and 10 were not resolvable.
There have been unusual problems with MetLife overpaying claims as secondary carrier by overlooking the “other coverage section” as well as the EOB of the primary. This has been occurring regularly with one dentist who must then return each overpayment. NJDA has requested that MetLife find the source of the problem and correct it so as not to inconvenience the dentists involved.
Delta Dental of California continues to process a periapical film as “each additional periapical” if bitewings are also taken. NJDA had previously discussed this matter with Delta of NJ, and the claims in question were re-processed and paid correctly. NJDA will write directly to Delta of California on this issue, since the policy is not consistent with the ADA code descriptor.
The council discussed DDP of Arizona’s development of a two tier reimbursement system; a higher level for those dentists who are “exclusive” to Delta, and a lower level for dentists who participate with other plans. Staff reported that if a significant number of Arizona dentists drop participation with other plans, it could trigger complaints to the Department of Justice as a violation of antitrust laws. According to the Executive Director of the Arizona Dental Association, many dentists are upset about Delta’s announcement of this new system.
The council reviewed correspondence sent to Delta Dental of Minnesota on behalf of a member dentist who had predetermined a three unit bridge for a patient. The predetermination was issued on July 4, 2005, indicating a plan payment of $1,005.00 with the limited disclaimer that the estimate was based on patient’s current eligibility and benefits. When the claim was submitted for payment, Delta paid only $76.70 with the reason for reduction said to be exhaustion of the annual maximum, which occurred some months prior to the predetermination date. NJDA has taken the position that Delta is liable for full payment due to the language of the limited disclaimer. Delta’s initial contact with NJDA was to inform staff that the patient’s authorization on the Claims Resolution form is not HIPAA compliant (it is). Subsequent to the meeting, NJDA received a letter stating that a response was sent directly to the dentist; this response was that no further benefits were payable on the claim. Another letter was sent to Delta, requesting that the matter be referred to its legal department. NJDA staff will continue to follow-up on this matter.
The council reviewed, as informational, minutes of the Advisory Committee formed by Aetna as part of the settlement agreement reached in the lawsuit. That discussion centered on offensive EOB language, some of which Aetna agreed to change. Aetna will also review the idea of claims not being auto-adjudicated if a narrative is attached, but routing them directly to a consultant. Currently, even if a narrative explanation is attached, the auto adjudication process is followed, and in most cases, the claims will deny. Further meetings will be held. The council noted that Dr. Pellegrini has been appointed to that committee by Aetna, and that future meetings are scheduled.
The council reviewed an article which appeared in the ADA News October 3, 2005 entitled “Knowing PPO’s” The dentist urged everyone considering PPO participation to examine closely the costs and benefits of each plan before signing the agreement. The council agrees that this issue points out the need for more educational programs for dentists to enable them to make appropriate business decisions.
Dentists are encouraged to fully incorporate Best Management Practices (BMPs) into their office routine. There is currently legislation being proposed that would require dentists install amalgam separators into their offices. The financial impact to dentists could be tremendous if enacted. NJDA is working to keep the impact to a minimum and hopes that by dentists employing BMPs voluntarily. This proactive approach could be used to convince legislators that dentists are on the forefront of amalgam waste management, thus avoiding costly regulations. ADA resources are available at www.ada.org/prof/resources/topics/amalgam_bmp.asp.
The council discussed legislation signed by Acting Governor Richard Codey on September 26, 2005 that allocates $35 million annually to support the state’s Federally Qualified Health Centers (FQHCs), nearly doubling current funding. New Jersey has 21 community health centers that operate 67 sites. Last year, these sites had more than 234,000 uninsured patient visits. Many of the centers operate a dental facility.
Staff briefed the council on legal and regulatory matters, most notably the fact that a dentist class was certified in the litigation filed by an oral surgeon against Horizon medical and dental plans for its alleged improper and untimely claims processing practices. The certified class consists of all participating and non-participating dentists, regardless of specialty.
Staff reported that the Department of Health and Senior Services will not revisit the fluoridation issue until the report is issued by the National Academy of Sciences (NAS), which is studying the current level of 4 ppm as the maximum contaminant level (MCL) for drinking water. That report is expected to be released in February 2006. Staff also
reported that the Hightstown Health Council is entertaining a request by residents to remove the fluoride from Hightstown’s water supply. One of NJDA’s members, Dr. John Laudenberger, sits on that council, and NJDA has been working with him to assist in defeating this initiative. Finally, the council reviewed the Time magazine article reporting on the developing new resistance to fluoridated water.
The council discussed, at length, how NJDA might do a more effective job in educating dentists about dental benefit issues. Various ideas were discussed including continuing education courses and more articles. Staff reported that the continuing education courses on the subject were not well attended, and that many dentists apparently do not read the Capsule. NJDA’s website, as well as ADA’s, also includes much information. Since more dentists read their component newsletters, staff will e-mail council members detailed information on the prompt payment regulations and a list of frequently asked questions, so that the council members can request that their component editors publish information periodically. Subsequent to the meeting, staff e-mailed the council with the idea of inviting all NJDA members (maximum of 20) to a future meeting of the council.
FAQs - CLAIM PAYMENT ISSUES
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. Federal regulations that govern “ERISA” plans state that decisions on post-service claims must be made within 30 days, but that does not mean claims must be paid within 30 days.
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: 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. Further, New Jersey’s prompt payment regulations require plans to provide to participating dentists (or enrollees as the situation dictates) a list of their documentation requirements for various services. This provision was intended to avoid situations in which payment was delayed due to the plan’s need for “further information”. The Department of Banking and Insurance has stated that it is not acceptable for a plan to make “random” requests for information on submitted claims.
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%). Failure to disclose waiver of copayment is considered insurance fraud.
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, but only if the administrative remedies of the plan (e.g., appeal process) have been exhausted. NJDA has been very successful in resolving problems. In 2004, NJDA received a total 151 complaints; of this number, only three were not resolvable because of a specific policy limitation not previously communicated. Thirty-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 on the part of specific plans. Contact NJDA’s Department of Dental Care Programs for a copy of the CRP form, which you should have the patient sign to authorize release of information to NJDA.