Dental Claims Research Articles

Medicaid Reforms in Oregon and Suboptimal Utilization of Dental Care by Women of Childbearing Age

The authors conducted a study of dental services used by women of childbearing age who were enrolled in Medicaid in Oregon during the early 2000s, a period of reform during which health care coverage was expanded. They compared claims for pregnant women, women who were not pregnant and had children and women who were not pregnant and did not have children. They also compared differences in claims between those for women enrolled in managed care and those for women enrolled in fee-for-service plans. The authors computed the proportion of women for whom a dental claim was submitted in six-month spans for 2000, 2001, 2002 (before reform) and 2005 (after reform). Before and after reforms, the mean utilization rate for pregnant women, adjusted for the proportion of the period covered, decreased from 0.36 (standard deviation [SD] = 0.025) to 0.22 (SD = 0.028). Among women who were not pregnant and had children, the average adjusted rates decreased from 0.49 (SD = 0.201) to 0.21 (SD = 0.078). The pattern was similar among women who had no dependent children: rates decreased from 0.50 (SD = 0.028) to 0.19 (SD = 0.078). Most of the claims were for diagnostic services. The authors found no differences between women enrolled in managed care and those enrolled in fee-for-service plans. Contrary to their intention, health care reforms in Oregon were detrimental to the vulnerable populations that Medicaid is intended to serve. Dental care is important for maternal and child health. However, utilization is unlikely to improve without changes in Medicaid and the dental care delivery system.

Preventive dental utilization for Medicaid-enrolled children in Iowa identified with intellectual and/or developmental disability

To compare preventive dental utilization for children with intellectual and/or developmental disability (IDD) and those without IDD and to identify factors associated with dental utilization. We analyzed Iowa Medicaid dental claims submitted during calendar year (CY) 2005 for a cohort of children ages 3-17 who were eligible for Medicaid for at least 11 months in CY 2005 (n = 107,605). A protocol for identifying IDD children was developed by a group of dentists and physicians with clinical experience in treating children with disabilities. Utilization rates were compared for the two groups. Crude and covariate-adjusted odds ratios were estimated using conditional logistic regression modeling. A significantly higher proportion of non-IDD children received preventive care than those identified as IDD (48.6 percent versus 46.1 percent; P < 0.001). However, the final model revealed no statistically significant difference between the two groups. Factors such as older age, not residing in a dental Health Professional Shortage Area, interaction with the medical system, and family characteristics increased one's likelihood of receiving preventive dental care. Although IDD children face additional barriers to receiving dental care and may be at greater risk for dental disease, they utilize preventive dental services at the same rate as non-IDD children. Clinical and policy efforts should focus on ensuring that all Medicaid-enrolled children receive need-appropriate levels of preventive dental care.

Preventive Dental Care for Young, Medicaid-Insured Children in Washington State

Children from low-income families face barriers to preventive dental care (PDC) and are disproportionately affected by dental caries. The Access to the Baby and Childhood Dentistry (ABCD) program of Washington State is targeted to Medicaid-insured children <6 years of age to improve their access to PDC. To test the hypothesis that residing in an ABCD county improves the likelihood of receiving PDC and, to compare PDC use among young, Medicaid-insured children in Washington to national statistics. We extracted 2003 Washington Medicaid dental claims for continuously enrolled children <or=6 years of age. Multivariable analysis was performed to identify variables independently associated with >or=1 preventive dental visit (PDV) in 2003. For national comparison, we used the 2003 Medical Expenditure Panel Survey (MEPS). Among Medicaid-insured children <or=6 yrs of age from WA counties with ABCD program, 45% had at least 1 PDV compared with 36% from non-ABCD counties (P < .001) and 37% of US children with continuous private insurance (P < .001). There were significantly higher adjusted odds of a PDV for children from ABCD counties relative to non-ABCD counties (odds ratio: 1.30 [95% confidence interval: 1.05-1.60]). We confirmed our hypothesis that residing in an ABCD county was associated with a higher likelihood of having >or=1 PDV in 2003. We also found that significantly more children in established ABCD counties received PDC compared with privately insured US children. These findings provide additional evidence that the ABCD program reduces disparities in dental care access among young, Medicaid-insured children in Washington and point to the importance of expanding the ABCD program to other states.

Assessing Patterns of Restorative and Preventive Care Among Children Enrolled in Medicaid, by Type of Dental Care Provider

The authors investigate the relationship of preventive dental treatment to subsequent receipt of comprehensive treatment among Medicaid-enrolled children. The authors analyzed Medicaid dental claims data for 50,485 children residing in Wayne County, Mich. The study sample included children aged 5 through 12 years in 2002 who had been enrolled in Medicaid for at least one month and had had at least one dental visit each year from 2002 through 2005. The authors assessed dental care utilization and treatment patterns cross-sectionally for each year and longitudinally. Among the Medicaid-enrolled children in 2002, 42 percent had had one or more dental visits during the year. At least 20 percent of the children with a dental visit in 2002 were treated by providers who billed Medicaid exclusively for diagnostic and preventive (DP) services. Children treated by DP care providers were less likely to receive restorative and/or surgical services than were children who were treated by dentists who provided a comprehensive mix of dental services. The logistic model showed that children who visited a DP-care provider were about 2.5 times less likely to receive restorative or surgical treatments than were children who visited comprehensive-care providers. Older children and African-American children were less likely to receive restorative and surgical treatments from both types of providers. The study results show that the type of provider is a significant determinant of whether children received comprehensive restorative and surgical services. The results suggest that current policies that support preventive care-only programs may achieve increased access to preventive care for Medicaid-enrolled children in Wayne County, but they do not provide access to adequate comprehensive dental care.

Preventive Dental Service Utilization for Medicaid-Enrolled Children in New Hampshire: A Comparison of Care Provided by Pediatric Dentists and General Dentists

In this study, we compared preventive dental utilization through visits to a pediatric dentist (PD) vs. visits to a general dentist (GD) among Medicaid-enrolled children in New Hampshire (n = 12,964). Dental claims were analyzed using conditional logistic regression models. After adjusting for covariates, children seen by a PD were 51% more likely to have received fluoride treatment, 26% more likely to have had at least two dental examinations, and 19% more likely to have received a sealant than children seen by a GD. Overall, our results suggest that children seen by a PD were more likely to have received preventive services than those seen by a GD. Because Medicaid-enrolled children are at increased risk for poor oral health, policies should be enacted to ensure that high-risk children receive appropriate and regular prevention-oriented dental care.

The development of dentist practice profiles and management

With the current large computerized payment systems and increase in the number of claims, unusual dental practice patterns to cover up fraud are becoming widespread and sophisticated. Clustering the characteristic of dental practice patterns is an essential task for improving the quality of care and cost containment. This study aims at providing an easy, efficient and practical alternative approach to developing patterns of dental practice profiles. This will help the third-party payer to recognize and describe novel or unusual patterns of dental practice and thus adopt various strategies in order to prevent fraudulent claims and overcharges. Knowledge discovery (or data mining) was used to cluster the dentists' profiles by carrying out clustering techniques based on the features of service rates. It is a hybrid of the knowledge discovery, statistical and artificial neural network methodologies that extracts knowledge from the dental claim database. The results of clustering highlight characteristics related to dentists' practice patterns, and the detailed managerial guidance is illustrated to support the third-party payer in the management of various patterns of dentist practice. This study integrates the development of dentists' practice patterns with the knowledge discovery process. These findings will help the third-party payer to discriminate the patterns of practice, and also shed more light on the suspicious claims and practice patterns among dentists.

Racial and ethnic disparities in nontraumatic dental-condition visits to emergency departments and physician offices: A study of the Wisconsin Medicaid program

Nontraumatic dental condition (NTDC) visits occur in emergency departments (EDs) and physician offices (POs), but little is known about factors associated with NTDC visit rates to EDs and POs. The authors analyzed all Medicaid dental claims in Wisconsin from 2001 through 2003 to examine factors associated with NTDC visits to EDs and POs. They performed bivariate and multivariable analyses. The independent variables they examined included race/ethnicity, age, sex, dental health professional shortage area (DHPSA) designation and urban influence code for county of residence. The authors evaluated 956,774 NTDC visits made during 1,718,006 person-years; 4.3 percent of visits occurred in EDs or POs. Native Americans, African-Americans and enrollees of unknown race/ethnicity had the highest unadjusted ED and PO visit rates for NTDCs. African-Americans, Native Americans, adults and residents in partial or entire DHPSAs had significantly higher adjusted rates of NTDC visits to EDs. The authors observed significantly higher adjusted NTDC visit rates to POs for Native Americans, adults and enrollees residing in entire DHPSAs, and a significantly lower adjusted rate among African-Americans. Native Americans, those residing in entire DHPSAs and adults have significantly higher risks of NTDC visits to EDs and POs. African-Americans are at increased risk of making visits to EDs for NTDCs but at decreased risk of making visits to POs for NTDCs. Reductions in Medicaid visits to EDs and POs and the associated costs might be achieved by improving dental care access and targeted educational strategies among minorities, DHPSA residents and adults.

Time to First Dental Visit After Initially Enrolling in Medicaid and S-SCHIP

Accessing dental care is a significant problem for children in Medicaid and S-SCHIP (Separate State Children's Health Insurance Program). Previous studies have indicated that the design of the Medicaid or S-SCHIP dental program can have an impact on the ability to use services. To evaluate the factors related to how quickly children had any dental visit and had a preventive dental visit after first enrolling in the Iowa Medicaid and S-SCHIP programs. The primary question was whether the structure of the dental plan was related to improved access to care. Iowa Medicaid and S-SCHIP dental claims and enrollment files for FY 2001 through 2003 were used to identify children who were newly enrolled in the programs and their use of dental services. Factors related to the time to a child's first dental visit were analyzed using survival analytic techniques. After 6 months in the program, between 21% and 36% of children had received their first dental visit, depending on their dental plan. This increased from 39% to 56% after 1 year. Based on the survival analysis, earlier dental utilization was related to the type of plan in which the child was enrolled as well as the child's age, race, and urban/rural location. Children in the S-SCHIP 2 dental plan, which had an open provider network and paid dentists' full charges, were most likely to have had a dental visit sooner after enrollment. States looking for options to improve access to dental care in their Medicaid and S-SCHIP programs should consider contracting with dental plans with these features.

Linking mother and child access to dental care.

Among young children in low-income families covered by Medicaid, we estimated (according to racial/ethnic group) whether children who have mothers with a regular source of dental care at baseline have greater dental use in the subsequent year than children with mothers without a regular source. From a population of 108151 children (aged 3 to 6 years) who were enrolled in Medicaid and their low-income mothers in Washington state, a disproportionate stratified random sample of 11305 children aged 3 to 6 was selected from enrollment records in 4 racial/ethnic groups: black (3791), Hispanic (2806), white (1902), and other racial/ethnic groups (2806). In a prospective cohort design, we conducted a baseline survey of mothers and for respondents collected their children's Medicaid dental claims in the 1-year follow-up period. Mutivariable regression models estimated the associations between the mothers' having a regular source of dental care at baseline and their children's prospective dental use. Approximately 38% of the mothers had a regular source of dental care. Among children of black and Hispanic mothers, having a mother with a regular source of dental care at baseline was associated with greater odds of receiving any dental care in the subsequent year. For children with dental use, children of black or Hispanic mothers with a regular source of dental care received 1.22 and 1.10 more preventive services, respectively. For children of white mothers, associations were in the same direction but not significant. For young children of black and Hispanic mothers, dental care use is higher when their mothers have a regular source of dental care. For low-income young children with Medicaid, increasing the mothers' access to dental care may increase the children's use of dental and preventive services, which, in turn, may reduce racial/ethnic inequalities in oral health.

A Comparison of Dental Service Use Among Commercially Insured Women in Minnesota Before, During and After Pregnancy

The authors examined and compared dental services used by women before, during and after pregnancy. In their study, the authors combined medical and dental claims data for 3,462 pregnant women in Minnesota with commercial dental insurance who had been pregnant between Jan. 1, 2004, and Dec. 31, 2005. The authors used McNemar pairwise comparisons, with each subject serving as her own control and her use of various dental services before pregnancy as her own baseline, to evaluate and compare the dental services used during and after pregnancy. During pregnancy, subjects' use of several dental services-radiographs, restorative services, third-molar extractions and anesthesia-decreased significantly (P < .001) in comparison with their prepregnancy use. After pregnancy, subjects' use of checkups, radiographs and restorative services showed significant increases (P < .001). The significant decreases in use of these services during pregnancy and significant increases after pregnancy may suggest that these women and their dentists were using these services only conservatively during pregnancy or postponing their use altogether until after delivery. This study's findings may provide useful background information to medical and dental providers, health care plan administrators and policymakers as they consider recommendations regarding oral health care for women during pregnancy.

The effect of two publicly funded insurance programs on use of dental services for young children.

The purpose of this study is to compare the use of dental services for preschool aged children enrolled in North Carolina Medicaid, a traditional program based on a fee-for-service schedule, and North Carolina Health Choice (NCHC), an State Children's Health Insurance Program (S-CHIP) dental insurance program structured similarly to private insurance. All children (165,858) 1-5 years of age enrolled in Medicaid and S-CHIP (NCHC) at some time during one study year (October 1, 1999-September 30, 2000). DATA SOURCES/EXTRACTION METHODS: Medicaid and NCHC enrollment and dental claims files were obtained for individual children. An observational study with a retrospective cohort design. Use of dental services for each child was measured as having at least one dental claim during the outcome period (October 1, 1999-September 30, 2000). Multivariable logistic regression models were developed to compare the effect of two differently administered insurance programs on the use of dental services, controlling for demographic, enrollment, and county characteristics. Children enrolled solely in S-CHIP (NCHC) were 1.6 times more likely (95 percent confidence intervals (CI)=1.50-1.79) to have a dental visit than those enrolled solely in Medicaid. Prediction models for children enrolled for 12 months indicated that those enrolled in S-CHIP (NCHC) had a significantly higher probability of having a dental visit (50 percent) than those enrolled in both plans (44 percent) or Medicaid only (39 percent), a trend found in all age groups. The S-CHIP (NCHC) program appears to provide children with increased access to dental care compared to children in the Medicaid program.

Determining Dental Utilization Rates for Children: An Analysis of Data from the Iowa Medicaid and SCHIP Programs

Accessing dental care is a significant problem for children in Medicaid and SCHIP. Evaluating the extent of the access problem is affected by the differential dental utilization rates as calculated by unique approaches used by national organizations. The problem is related to the intermittent enrollment in Medicaid and SCHIP for many children during the year. The objective of this study is to evaluate the effect of four different approaches for calculating dental utilization rates for children in Medicaid and SCHIP programs. All Iowa Medicaid and S-SCHIP dental claims and enrollment files for CY 2001 were used to characterize the populations, calculate dental utilization rates and evaluate the types of services received by dental utilizers. Dental utilization rates were calculated four ways using the following different rate denominators: 1) any child enrolled during the year (Center for Medicare and Medicaid Services method), 2) children enrolled for 11-12 months (National Committee for Quality Assurance method), 3) a full-time equivalents (FTE) method, 4) only newly enrolled children. The methodology employed greatly affected the dental utilization rates. Rates varied from 18% for newly enrolled children in Medicaid to 58% for S-SCHIP-enrolled children using the FTE method. Methods that included children who were more likely to be in for more months during the year, such as the NCQA approach, produced the highest rates. The method used to determine the dental utilization rates for Medicaid and SCHIP enrollees should be clearly stated when these rates are being presented. This will allow the reader to be able to make a careful and appropriate interpretation of the results.

Travel insurance claims made by travelers from Australia.

Little is known about travel insurance claims made by travelers returning from abroad. This study was designed to investigate travel insurance claims made by travelers from Australia, particularly examining demographic factors, type of travel insurance coverage, nature and duration of travel, when treatment was sought during travel or when the problem arose, use of emergency assistance, nature of claim, and claim outcome, including cost. A random sample of approximately one in five claims reported during the period 1996 to 1998 to a major Australian travel insurance company were examined. A total of 855 claims were examined, of which 42.6% (356/836) were made by male travelers and 57.1% (477/836) were made by female travelers. The majority of claimants were in the 55 years and over age groups (445/836, 53.2%). Medical and dental conditions accounted for 66.6% of claims (569/854), with the remainder associated with loss, theft, and damage (285/854, 33.4%). The most common medical conditions were respiratory (110/539, 20.4%), musculoskeletal (90/539, 16.7%), gastrointestinal (75/539, 13.9%), ear, nose, and throat (67/539, 12.4%), and dental conditions (39/539, 7.2%). Only one case of venous thrombosis was reported, secondary to a lower limb infection. Use of the travel insurance company's emergency telephone service was reported in 17.1% of claims (146/853). Almost two-thirds (559/853, 65.5%) of claims were fully accepted. Those who claimed medical treatment, assault, and theft were significantly more likely to have their claims accepted compared to those claiming dental conditions, cancellation, curtailment, loss and damage (chi2 = 127.78, df = 40, p <.00001). The majority of medical and dental conditions did not require further medical investigations (427/569, 75.0%). The mean cost of claim refunds was Australian dollars (AUD)991.31 (standard deviation [SD] 6 AUD5400.76) for males and AUD508.90 (SD 6 AUD1446.10) for females. Claims for assault, cancellation, and curtailment were significantly more expensive than other types of claims (Kruskal-Wallis one way analysis of variance [ANOVA]; chi2 = 106.87, df = 8, p <.00001). Claims for treatment of gastrointestinal, cerebrovascular, cardiovascular, musculoskeletal conditions, and pyrexias of unknown origin were significantly more expensive than other medical and dental claims (Kruskal-Wallis one way ANOVA; x2 = 61.68, df = 15, p <.00001). This explorative study highlights the importance of travelers taking out appropriate travel insurance. Claims for medical and dental conditions represent the majority of travel insurance claims made by Australian travelers returning from abroad, although travel insurance also covers against such contingencies as loss, theft, and cancellation. The most common medical conditions claimed were respiratory, musculoskeletal, and gastrointestinal disorders. Travelers should be advised to take out appropriate travel insurance before departure overseas and to take care with preexisting medical and dental conditions, which may not be able to be claimed against travel insurance.

Dental claims - should I take this case on?

Dental claims - should I take this case on?

Successfully funding dental negligence claims

Successfully funding dental negligence claims

An evaluation of mouthguard requirements and dental injuries in New Zealand rugby union

Objectives: To document the effects of compulsory mouthguard wearing on rugby related dental injury claims made to ACC, the administrator of New Zealand’s accident compensation scheme. Methods: An ecological study...

Relationships between Behavioral Risk Factors and Dental Care Costs in a Japanese Worksite

To identify the magnitude of dental care costs and examine the relationship between behavioral risk factors and dental care costs in a Japanese corporation. A one-time cross-sectional design was used with each employee as a unit of analysis. The setting was a large Japanese corporation where Japan's standard health care insurance, including dental care coverage, was provided for all employees. A full-time employee population of 6543 was included. Seventy-six percent were men, and the majority were white-collar workers. Data were available on dental care costs and self-reported behavioral dental care risk, including smoking and oral self-care, obtained from the company's annual physical checkups in the 2000 fiscal year Dichotomous variables of expenditures for employees having no dental claims and those having high claims defined as 90th percentile or above were created. The dental care costs made up approximately 24.3% of the health care costs. Thirty-five percent of the employees were smokers. Employees who were at least 40 years old and employees who were women were associated with the likelihood of using dental care services (odds ratio [OR] = 1.622 and 0.783, respectively), and no behavioral risk was associated. The likelihood of incurring high dental care costs was associated with smoking when including all employees in addition to those who used any dental care services (OR = 1.315 and 1.386, respectively). This study suggests the relationships of smoking as well as age and sex to dental care costs in an employer setting. To provide a strong case for health promotion in Japan, future research should address critical issues such as reliable and valid risk measurement and the use of longitudinal designs and intervention studies.

Effects of Global Budgeting on the Distribution of Dentists and Use of Dental Care in Taiwan

To examine the effects of global budgeting on the distribution of dentists and the use and cost of dental care in Taiwan. (1) Monthly dental claim data from January 1996 to December 2001 for the entire insured population in Taiwan. (2) The 1996-2001 population information for the cities, counties and townships in Taiwan, abstracted from the Taiwan-Fukien Demographic Fact Book. Longitudinal, using the autocorrelation model. Results indicated decline in dental care utilization, particularly after the implementation of dental global budgeting. With few exceptions, dental global budgeting did not improve the distribution of dental care and dentist supply. The experience of the dental global budget program in Taiwan suggested that dental global budgeting might contain dental care utilization and that several conditions might have to be met in order for the reimbursement system to have effective redistributive impact on dental care and dentist supply.

Emergency assistance provided abroad to insured travellers from Australia

Emergency assistance provided on behalf of travel insurance companies may include direct services such as medical advice, referral for local medical or dental treatment abroad, or aeromedical evacuation (AME) back to Australia or a third country. Little is known about the nature of these services provided by emergency assistance services on behalf of travel insurance companies. This study is designed to investigate the nature of emergency assistance provided abroad to travellers from Australia. All travel insurance claims reported during 2001 to a major Australian travel insurance company were examined for those claims utilising the insurer's emergency assistance service. Four hundred claims (25.3%) reported utilising emergency assistance Medical and dental claims made up over two thirds of claims requiring emergency assistance (275, 69.3%), with cancellation and curtailment, mostly for medical reasons, making up more than one eighth of claims (59, 14.8%). The most common nature of illness requiring emergency assistance was musculoskeletal disorders (87, 28.2%), followed by gastrointestinal disorders (45, 14.6%), dental conditions (42, 13.6%) and respiratory problems (36, 11.7%). The problem reportedly occurred at a median of 19.5 (range=281.0) days into travel. Emergency assistance provided included policy advice (395, 99.0%), claiming advice (394, 98.7%), civil advice or assistance (79, 19.8%), medical advice or GP referral (22, 5.5%), hospital emergency room (ER) review (58, 14.5%), hospital admission (46, 11.5%), medical or dental follow-up (25, 6.3%) and AME (10, 2.5%). Use of the travel insurer's emergency assistance service was reported by about one quarter of claimants. In most cases, travellers sought simple claiming and policy advice, however, the emergency assistance service occasionally co-ordinated the provision of direct medical services. AME was an uncommon but expensive form of emergency assistance. Further research is needed into how useful the services provided by emergency assistance services of travel insurance companies were to the travellers that use these services.

Travel insurance and medical evacuation

Despite an improved understanding of serious injury and illness during travel, accidents, near accidents, and maladies continue to befall tourists. With knowledge of these risks, travellers should be armed with preventive strategies, emergency treatment supplies, a working knowledge of first aid, and appropriate travel insurance coverage. Travellers should know how to access appropriate care at their travel destination, ideally through the emergency assistance service of their travel insurer. The traveller should understand the indications for and logistics of emergency assistance and aeromedical evacuation. Travel insurers normally underwrite travel, medical, and dental expenses incurred by travellers abroad, who take out "travel insurance", and provide emergency assistance and arrange aeromedical evacuation of travellers under specified conditions. Medical and dental claims make up more than two-thirds of all claims (Leggat & Leggat, 2002). Travellers sbould be advised 10 read their policies carefully to see what is covered, the level of the excesses, and to check for any exclusions. In particular, those travellers who have known pre-existing conditions, who are working long-term overseas, or who are going to undertake any form of hazardous recreational or occupational pursuit may need to obtain a special travel insurance policy, and this may attract a higher premium. In addition, travel insurance companies normally provide a service, usually through their emergency assistance contractors, to assist travel1ers abroad. This may include assisting with medical care while overseas, including aeromedical evacuation. Use of the emergency telephone service provided by the travel insurance company was reported in almost one-fifth of claims in a recent study of general claims in Australia (Leggat & Leggat, 2002). In a recent Swiss study, more than two-thirds of claims made through the travel insurer's assistance centre were for illness, while the remainder were due to accidents (Somer Kniestedt & Steffen, 2003). The risk of severe injury is thought to be greater for people when travelling abroad (Bewes, 1993). This chapter reviews the general nature of travel insurance and the mechanics and practical considerations of emergency assistance and aeromedical evacuation.