Abstract
The objective of this study was to assess the prevalence and the type of claim denials (administrative, clinical or both) made by a large dental insurance plan. This was a cross-sectional, observational study, which retrospectively collected data from the claims and denial reports of a dental insurance company. The sample consisted of the payment claims submitted by network dentists, based on their procedure reports, reviewed in the third trimester of 2012. The denials were classified and grouped into 'administrative', 'clinical' or 'both'. The data were tabulated and submitted to uni- and bivariate analyses. The confidence intervals were 95% and the level of significance was set at 5%. The overall frequency of denials was 8.2% of the total number of procedures performed. The frequency of administrative denials was 72.88%, whereas that of technical denials was 25.95% and that of both, 1.17% (p < 0.05). It was concluded that the overall prevalence of denials in the studied sample was low. Administrative denials were the most prevalent. This type of denial could be reduced if all dental insurance providers had unified clinical and administrative protocols, and if dentists submitted all of the required documentation in accordance with these protocols.
Highlights
The private healthcare sector, regulated in Brazil by law 9656/98 and supervised by the National Agency of Supplemental Health (ANS - Agência Nacional de Saúde Suplementar, in Portuguese), has grown in the country
Data collection The claims review process takes place according to the following steps: the network dentist submits a report to the insurance company on the treatments administered to patients as codified in the Dental Treatment Request (GTO - Guia de Tratamento Odontológico, in Portuguese) and in the Professional Service / Auxiliary Diagnostic and Therapeutic Service request forms (SP/SADT – Guia de Serviço Profissional/ Serviço Auxiliar de Diagnóstico e Terapia, in Portuguese), following the standards used in the Health Insurance Information Exchange manual (TISS - Troca de Informação em Saúde Suplementar, in Portuguese)
Even though it was considered to be low, this rate could have been even lower if dentists submitted documentation following the administrative criteria established by the Health Plan Operators (HPO) and provided services following the principles of evidence-based dentistry
Summary
The private healthcare sector, regulated in Brazil by law 9656/98 and supervised by the National Agency of Supplemental Health (ANS - Agência Nacional de Saúde Suplementar, in Portuguese), has grown in the country. It has become indispensable, considering that the public sector is unable to fully meet the demand for healthcare services. The government oversees and regulates the solvency of Health Plan Operators (HPO). This regulation is two-fold: macro and microregulation. Microregulation is conducted at the claims review level, through protocols stipulated by the operator to the service providers.[3]
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