1 ODA Suggested Fee Guide and Dental Plans: Best Practices 2019 P RESENTED BY: LESLIE REDMOND, RDH ASSISTANT D ENTAL INFORMATION OFFICER ODA PRACTICE ADVISORY SERVICES • Introductions • Housekeeping Welcome • Identify and apply principles required to develop fees and report services using the ODA Suggested Fee Guide, acknowledging the link to professional conduct. • Identify the roles and responsibilities of the dentist as they relate to dental plans • Be familiar with the key aspects and the importance of record keeping and documentation as it relates to reporting and communicating with third party payers Learning Objectives Part 1: The ODA Suggested Fee Guide Part 2: The Dentist/Patient Relationship Part 3: Dental Plans Part 4: The Dentist/Plan Administrator Relationship Agenda 1 2 3 4
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ODA Suggested Fee Guide and Dental Plans:
Best Practices2 0 1 9
P RE S E NT E D BY: L E S L IE R E D MO ND, R D HA S S I S TANT D E NTAL I NFORM AT I O N OFF I CE R
O D A PR AC T I C E AD V I S OR Y S E RV I C E S
• Introductions
• Housekeeping
Welcome
• Identify and apply principles required to develop fees and report services using the ODA Suggested Fee Guide, acknowledging the link to professional conduct.
• Identify the roles and responsibilities of the dentist as they relate to dental plans
• Be familiar with the key aspects and the importance of record keeping and documentation as it relates to reporting and communicating with third party payers
Learning Objectives
This Photo by Unknown Author is licensed under CC BY-SA
Part 1: The ODA Suggested Fee Guide
Part 2: The Dentist/Patient Relationship
Part 3: Dental Plans
Part 4: The Dentist/Plan Administrator Relationship
✓ Be familiar with the paper copy• Read the Preamble
✓ Understand the code descriptions and the notes• Avoid misuse or abuse of codes
✓ Know the factors that influence fees• Use the notes and highlighted sections
➢ Using the Guide
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The “white pages”
• Memorandum from the Economics Committee• Table of Contents and Index• Foreword• “Use the Guide”• Preamble
Notes
• Provide a standardized language
• Are taken from the CDA’s USC&LS
• Identify unique and specific procedures
• Are not discretionary
Procedure Codes in the Guide• Fees in the Guide are Suggested (Foreword)
• are fair and reasonable under normal conditions• ODA has a policy on fee ranges
Suggested Fees in the Guide
This Guide is published by The Ontario Dental Association. The Guide is based on the provision of dental services which are performed under normal conditions and is intended to serve only as a reference for the general practitioner to enable development of a structure of fees which is fair and reasonable to the patient and to the practitioner. The Guide is not obligatory and each practitioner is expected to determine independently the fees which will be charged for the services performed. This Guide is issued merely for professional information purposes, without any intention or expectation whatsoever that a practitioner will adopt the suggested fees.
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• Requests from Members
• Protocol and requirements for assessment• https://www.youroralhealth.ca/member/index.php/practice-management/publications/2-practice-
Part 4: The Dentist/Plan Administrator Relationship
Agenda
➢ Requests for Additional Information
➢ Profiling and Auditing
Communicating with Plan Administrators
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• Information needed to determine eligibility
• Must obtain patients’ consent
• Provide copies only
• Provide a description of the clinical condition
➢ Requests for Additional Information
• Determines misuse of dental plans
• Profiling is a review of all claims
• Auditing is an investigation
➢ Profiling and Auditing
• Use only your UIN for your treatment
• Keep detailed records
• Use accurate procedure codes
• Provide sufficient supporting information
Preventing an Audit
• Read the Fee Guide preamble• Choose the correct code• Fees are suggested• Best practices for claim form submission• Communicate with your patients• Protect your relationship with your patients
➢ Summary
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➢ ODA Practice Advisory Services
Monday to Friday, 8:30 am to 4:30 pm
1. Who is ultimately responsible for choosing the correct procedure code and determining the fee for a dental procedure?a) The dental receptionistb) The principal dentistc) The treating dentistd) The dental plan sponsore) All of the above
Independent Assessment
2. To accurately select the procedure code which of the following must be considered?
a) The patient’s ageb) The instrument usedc) The dental plan coveraged) The intent of the treatmente) All of the above
3. Which of the following statements is false?a) When consenting to receive dental treatment, the
patient/parent accepts responsibility for 100% of the costs of the treatment.
b) The dental plan sponsor is liable for all expenses associated with their employees’ utilization of the dental plan.
c) The dental plan administrator is responsible for identifying dental plan misuse
d) The dentist is responsible for knowing the terms and eligibility for coverage for all patients’ dental plans
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4. How is 1 unit of time measured for procedures that are reported as “per unit of time”?
a) 15 minutes equals 1 unit of time.b) It depends on what a unit of time is on the appointment
schedule.c) It depends on the patient’s dental plan coverage.d) All of the above, it is discretionary.
5. Which of the following actions should be taken when a dental plan administrator request information from a patient’s dental record?a) Document the patient’s/parent’s express consent to share
personal health information.b) If radiographs are requested provide copies of existing
radiographs only.c) Provide a letter of expertise describing the patient’s
clinical condition and details of the planned or completed treatment in lieu of a radiographs where the clinical condition is not evident on radiographs or radiographs are not available.
