My name is Dr. S. Timothy Rose. I am a practicing periodontist in Appleton, Wisconsin, and the President-Elect of the American Dental Association. The ADA is a membership organization representing 74% of all dentists in the United States. It is my pleasure to appear this afternoon before the National Committee on Vital And Health Statistics’ Subcommittee on Health Data Needs, Standards, and Security.
This statement summarizes the views and concerns of the dental profession regarding health care claims attachments. The ADA supports the NCVHS recommendation that the Secretary adopt the X12N 837 transaction set for the standard electronic health care claim.
Regarding claims attachments, the ADA believes the following:
Dental claims attachments are unnecessary. These attachments do not provide new clinical information, but rather are requested by third party payers as a means to verify the diagnosis and/or completion of treatment as attested to by the treating dentist. As such, they are often redundant and unnecessarily contribute to the cost of claims processing for both providers and payors. Indeed, many payers do not want attachments and return them. Other third party payers require attachments nearly 100 percent of the time. Properly submitted claims contain adequate information about the patient, the treatment plan, and the provider to determine eligibility and applicable plan benefits. Attachments for dental claims should cease to be a routine part of the process.
Providing attachments is costly. At the present time only 30% of dentists who have the capability of accessing an external data network actually submit claims electronically. Reasons given for this low percentage include the following:
Let me remind the committee that over 80 percent of practicing dentists are solo practitioners, and over 97 percent practice in groups of three or fewer. The decision to invest in computer automation can have considerable impact on a practitioner’s bottom line, especially given the frequent changes in today’s technology. The transmission of electronic radiographic images requires huge amounts of storage capability and is not cost effective for the average dentist.
As requested by the committee, I have provided answers to the following questions.
What types of claims attachments do you currently provide to payers? In what format do you provide such information? Typical dental claims attachments include copies of radiographs and less often, study models, periodontal charts, and photographs. These are provided in hard copy.
What other types of documentation do you currently provide to payers? In what format do you provide this information? None.
What purpose(s) do these attachments and other documentation serve? These attachments serve to satisfy payers’ desires to verify diagnosis in determining allowable benefits.
How much do these requests differ across payers? Could these requests for claims attachments and additional documentation be classified and standardized across payers? Requests and/or requirements for attachments vary considerably among payers and would benefit from standardization as part of conversion to electronic claims administration. Some payers have an almost 100 percent request for claims attachments while others seldom request them. Again, it is our position that eliminating attachment requests altogether should be the industry goal.
What aspects of these processes would be aided by standardization and electronic exchange of information? Standardization could reduce the frequency of requests and provide uniformity to the process, thereby reducing costs.
What is the relationship between claims attachments and the medical record?
Attachments serve to satisfy payers’ desire to verify diagnosis in determining allowable benefits. Dental claims attachments are part of the medical record and, therefore, deserve all the protections accorded by medical privacy and confidentiality laws and regulations.
Do you ever submit the entire medical record to payers in support of the claim? Under what circumstances is the entire medical record submitted? Rarely, if ever, is the entire dental record submitted. Attachments should only be submitted when specifically requested by the carrier to adjudicate the claim.
Would standardization and simplification of the questions asked by the payer make the claim adjudication process easier? Yes. Standardization would reduce costs, reduce the number of claims returned for incomplete information, and improve the overall processes of providing oral health care.
Do you have any suggestions that would assist us in the task of standardizing the requests for additional information from payers? With regard to dental claims, it should be recognized that requests for attachments tend to be redundant to the information included on the standardized claim form. Standards should be developed as to when attachments may be requested. The use of soon to be available dental diagnostic coding information should also eliminate the need for dental attachments altogether.
Would the automation of health care claim attachment information and standardization of the payers' requests for information reduce operating costs for your facility? Yes and no. Standardization of payers’ requests would reduce costs unless dental offices were required to provide electronic transmission of radiographs which then would increase costs. The technology required to digitally reproduce, store, catalogue, and transmit the images is expensive and constantly changing. While storage capacities and processing speeds may increase, the cost of software and hardware equipment remain fairly high.
Can you clearly differentiate “clinical information”, "claims information”, and “attachment information”? Yes. Clinical and claims information are provided on the standardized dental claim form. Dental attachment information reinforces the clinical information provided on the claim form.
Are there health care claim attachments that do not contain “clinical” information? Not in dental claims attachments.
Currently, the NUCC and the NUBC have the responsibility for approving the content of information contained in the standard health care claim. Do you think such an organization should also have responsibility for approving the content of claims attachments? Can you suggest which organization(s) should have this responsibility? As I have already stated, we believe attachments for claims should be eliminated at some point. In the interim, the ADA is the most logical choice of organizations to have the responsibility of approving and coordinating among interested parties the content of dental claims’ attachments.
3. Does your automated information management system have the capability to create a standard electronic health care attachment? Most dental offices at the moment are not capable of electronically transmitting radiographs. My office does not yet use such equipment, but will in the near future.
S. Timothy Rose, D.D.S., M.S., a periodontist in Appleton, Wisconsin, is president-elect of the American Dental Association. He will assume the ADA presidency in October, 1998.
His previous responsibilities with the ADA include serving on the Board of the Association for four years as Trustee from the Ninth District. He has also been chairman of the Association’s committee on information technology.
A graduate of the Ohio State University College of Dentistry, Dr. Rose is currently president of the American Academy of Periodontology. He is past president of the Wisconsin Dental Association, the Wisconsin Society of Periodontists, and the Midwest Society of Periodontology. He served on the Governor’s Task Force on the Future of Dentistry in Wisconsin.
Dr. Rose and his wife, Virginia, are the parents of a daughter and two sons.