Seven Things Adjusters Need to Know About Managing WC Dental Claims

2. Appropriate Treatment Plans. By nature, dentists are accustomed to treating the whole mouth, which in the workers' compensation world can lead to over-treatment and drive costs for services unrelated to the injury.  For example, an injured worker may have a simple chipped tooth, but the payer may receive a $20,000 dental bill because the worker had four cavities, a history of periodontal disease, and gingivitis.

To address this issue, a specialty network will have its dentists perform a prospective oral evaluation to determine what is compensable in regard to the work-related injury. They will then present an injury-related dental care plan to the adjuster or nurse case manager for review and approval.

In addition, as with other medical services, a dental claim is expedited when the injured worker receives access to the right provider or specialist at the right point in the treatment and recovery process. Given the infrequency with which claims professionals deal with dental claims, this can be difficult to coordinate. Payers and claims professionals should look to partner with a specialty network, as it has ready access to providers in close proximity to injured workers, as well as appropriate dental specialists that may be needed.

For instance, claims professionals can work with a dental network to:

• Coordinate dental appointments within 24 hours
• Call the claimant to assist in scheduling
• Obtain transportation and translation when needed
• Streamline paperwork for the dental provider and give the provider authorization on what may be done at the first appointment so there are no hidden costs.

 3. Access to Dental Specialists. Does the injury require a periodontist, an endodontist, an oral maxillofacial surgeon, or all three? What about a general dentist or prosthodontist? There are a number of specialties in the dental profession, and it can be challenging to determine what type of specialized care the injury requires. A specialty network has the dental expertise to make recommendations and referrals to specialists.

4. Clinical Support and Advice. Dental claims range from simple to highly complex. For example, many dental implant cases require surgeries and significant healing time, as well as considerable clinical oversight. Sometimes dental care is needed to help heal an infection in the mouth before a surgery. Or the patient may have other conditions that complicate or delay dental treatment such as the use of blood thinners, anesthesia complications, diabetes, smoking, or osteoarthritis.

A specialized dental network has a clinical team focused on various types and levels of dental claim complexity. For example, medical-only claims such as a chipped tooth or resin composite filling (drill & fill), are typically handled in one or two dental visits. If the treatment plan is more complicated and two or more providers are required, multi-specialty provider coordination is usually necessary. These claims may also involve care from an oral surgeon and could be open from two weeks to several months.

5. Complex Cases. Some complex cases can remain open for two months or longer. In these instances, a dental network can provide a team of care coordinators and clinicians who have five or more years of dental experience. The care coordinators are the equivalent of catastrophic claims adjusters in terms of expertise. They can assist in determining the right specialists to engage and help find a qualified dental provider.

6. Setting Dental Reserves. Just as with other workers' compensation claims, appropriate reserves must be set for dental injuries based on an estimation of the services that will be needed through the life of the claim. This determination can be complicated because, as noted, multiple services may be needed from various specialists. A specialty network has in-depth knowledge of dental procedures and pricing and can work with adjusters to set appropriate reserves, providing a treatment plan with estimated costs to ensure that proper funds are set aside.

7. Managing TMJ Cases. Temporomandibular joint (TMJ) disorder is a joint injury that could be caused by anything from a punch in the jaw to post-traumatic stress that triggers grinding of the teeth and jaw. It is one of the most problematic and potentially costly dental-related injuries.

Treatment can range from injections to relax the muscles around the jaw to complete joint replacement. Equipment may also be part of the claim, as some patients require bite guards or retainers. To illustrate how costly these injuries can be, a typical claim for joint replacement, fat grafting, and injections sometimes can exceed $100,000.

TMJ may result in a small permanent impairment rating. Recovery is challenging because patients cannot rest the jaw; a personal stress or bump may retard recovery or even require that treatment begin again. The complexity of the treatment and ease of re-injury are two reasons why TMJ claims can have a long tail.

For TMJ cases, as with other complex dental conditions, a specialized dental network can support claims professionals with a team of highly trained and experienced care coordinators who provide information and services to see that the claim is managed appropriately and clinical services are provided quickly and efficiently. 

Dental claims require special handling, clinical oversight, and ongoing management. Finding the right provider or specialist is the first challenge that claims professionals face with this type of injury, followed by the extensive time and in-depth expertise required to manage the claim through its cycle, which often can be considerably longer than other types of therapy.