Yes, you heard me correctly - dental plans need dentists just as patients do. Dental plans experience aches and pains, require remedies, and need ongoing maintenance too. If you don't have a knowledgeable and experienced dental consultant associated with your plan, it is likely to be out of date regarding professional and plan management perspectives.

There was a time when dental consultants to benefit plans were primarily used to review designated claims for dental necessity, appropriateness, and proper reimbursement. While this activity is still important in light of the recent technological explosion of new treatments and the continued escalation of dental fees, the knowledge and skill sets of a seasoned and qualified dental consultant now have broadened in response to professional, industry, and marketplace changes. An experienced consultant can provide valuable insight and input regarding provider network issues, dental claim policy and standards of care, dental plan coverage, and utilization management. A closer review of these areas will illustrate some of the more evident opportunities for dental plan improvement that a dental consultant can provide.

Network Management
If your plan has, or intends to have, network-based dental products, a dental consultant can assist in developing and assessing credentialing criteria for network dentist participation. The dental profession has its bad apples. An ongoing evaluation of a dentist's professional disciplinary history, utilization profile, and complaint patterns provides risk and quality management to the dental benefit program.

Another major role a dental consultant can play is as a problem solver with appeals or when events go awry between patient and provider. Are the events explainable? Are they born in patient non-compliance or technical inadequacy? How do any special circumstances relate to benefit coverage? Knowing how to approach the dentist and patient, and how to use peer review and the local Board of Dental Examiners can preclude legal involvement of all parties. The dental consultant is often best positioned to exact fairness and accountability.

Claim Policy and Standards of Care
A dental consultant can bridge the gaps between what dental services are rendered and reported on claims with the contract language. For example, standard plan language covers two evaluations per benefit period. With the new CDT 4 (i.e. ADA procedural codes) changes, there are now nine different evaluation codes or descriptors. Which ones does your dental plan cover in administering the frequency limitation? Does it make sense to apply the limitation to all the codes?

Inherent to dentistry is there are often multiple ways to treat the patient's problem (i.e. good/better/best). When a dental claim is submitted, is it the plan's intent to cover the least expensive- professionally acceptable treatment, or to benefit a Cadillac� level of care? The aforementioned are but two examples that illustrate the dental claim-plan coverage gap. The number of potential gaps recently increased due to the introduction of more than 125 new, deleted, or modified dental codes and descriptors. A qualified dental consultant brings a knowledge of scientific, evidence based treatments and professional standards of care to the plan upon which sound claim policy is established. Professional standards would include ethical standards, patient abandonment guidelines, and risk management principles. These knowledge sets are critical to managing utilization, costs, and quality.

Dental Plan Coverage
Dental consultants can also apply their knowledge of evidence-based dentistry to dental plan coverage. Dental benefits should be reserved for dental services that are necessary (i.e. the pre-conditions to warrant treatment are present), appropriate (i.e. the prescribed services are neither deficient nor excessive to the diagnosed problem), have a good prognosis (i.e. likelihood for a successful outcome), and meet generally accepted standards of care (i.e. based on scientific evidence). With the ongoing technological explosion of new dental therapies, professional guidance is needed to ensure your plan contract language is clinically current and supports the overall objectives of the dental plan. As example, dental implants are a proven treatment modality to replace missing teeth in certain clinical circumstances, while benefiting all porcelain ceramic crowns on back teeth may not be the recommended adjudication to maximize dental benefit dollars.

Many dental plans still contain archaic language from when dental plans first germinated in the 1960s. A qualified dental consultant can help ensure that dental benefits are made available to the very best that dentistry has to offer. However with the rapidity of professional change, this requires ongoing plan diligence and maintenance.

Utilization Review
Dental trend factors continue to outpace most other leading economic indicators. Coupled with the significant increases in healthcare costs, some purchasers may be re-evaluating their dental plans with more scrutiny. A dental consultant's close inspection of the charge and utilization data can assist in pinpointing claim-cost drivers. This information can be most useful in focusing utilization management resources on designated claim types, procedure codes, and dental providers. The qualified dental consultant's analysis of utilization data can also reveal where changes may be warranted in plan coverage and dental policy.

Qualified Dental Consultants
A qualified dental consultant requires diverse knowledge and skills as summarized in this article. Your typical family dentist will not generally meet the criteria and requirements of this role. So, where might one go to find a qualified dental consultant? The American Association of Dental Consultants (AADC) is an organization that represents dental consultants who work with dental benefit plans. AADC provides ongoing educational workshops and a certification program for its members. To find out more about AADC or a dental consultant in your area, please call 1-800-896-0707.