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Before concluding that dental claims are like the mythical unicorn—often rumored but rarely sighted—consider the numerous workers’ compensation scenarios that can involve damage to the mouth or jaw:
- Car accidents
- Workplace violence
- Construction and manufacturing accidents
- Slips and falls
In general, many injuries which involve body parts from the neck up will likely include some type of dental-related injury.
In addition to workplace accidents, the experience of pain itself can cause a problem with the jaw or mouth. For example, frequent teeth gnashing or grinding is a cause of TMJ (temporomandibular joint) disorders. TMJ problems, which can also be caused by an injury itself, are particularly problematic, and expensive, because they can require extensive reconstruction and are subject to easy re-injury.
There are three reasons why dental claims are particularly challenging for the claims manager:
- Multiple provider visits. Unlike most workers’ compensation services such as MRIs and X-rays, which are only required once or twice during the course of the claim, dental work may require multiple visits over time to different types of providers. As noted, the average dental claim requires 17 visits with the dental provider.
- Infrequent occurrence. Because dental claims are uncommon, and tend to be complex, there can be a lack of protocols and guidance on how to manage them.
- Ease of overtreatment. Overtreatment can easily occur, especially if the injured worker has not received regular dental care. In these cases, the dentist may treat problems throughout the entire mouth, not just the injury.
Here are some of the most frequent issues claims professionals face in managing dental claims, and advice from Express Dental on how to address and resolve each one.
1. Finding the right dentist. Or even any dentist who can handle a work-related injury. Until recently, dental networks for workers’ compensation did not exist. Most dentists are still not familiar with workers’ compensation and do not accept workers’ compensation patients. One major reason for their reluctance is a lack of understanding about how they will receive payment. They are also wary of the administrative costs of completing the unfamiliar paperwork required by the state.
Express Dental Care resolved this problem by developing their own network of 16,000 credentialed dentists throughout the United States, so that a qualified provider who understands workers’ compensation injuries, documentation and billing, is conveniently available close to the injured worker.
Through the experience of building and educating its network, Express Dental Care found that once dentists understand the system, they are more willing to accept workers’ compensation referrals, especially if there is a likelihood the injured worker will become a regular patient.
To further support the dentist in managing the workers’ compensation case, Express Dental Care provides him or her with a packet that includes instructions to perform an oral evaluation of the mouth, the proper forms to complete, and guidelines for them to treat only the injury and not non-injury-related conditions.
2. Selecting the right dental specialist. 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 just what type of specialized care the injury may require. Making this important decision can be made easier with advice from dental specialists like Express Dental Care.
3. Obtaining the right level of clinical support and advice, based on the injury and potential comorbidities of the patient. Dental claims range from simple to highly complex. Many implant cases in particular require surgeries and significant healing time, as well as considerable clinical oversight. Sometimes dental care is required to heal an infection in the mouth before a surgery can be done. Or, the patient may have other conditions that complicate or delay dental treatment, such as blood thinners, anesthesia complications, diabetes, smoking, osteoarthritis.
Express Dental Cares’ clinical teams focus on particular types and levels of dental claim complexity. Team members have extensive experience in the types of claims to which they are assigned. For example, “medical only” claims such as chipped teeth, resin composite fillings (drill & fill), are typically handled in 1–2 dental visits. If the treatment plan is more complicated and two or more providers are on the file, multi specialty provider coordinators are available to assist. These claims usually involve care from an oral surgeon or endodontist and are open from two weeks to 2–3 months.
4. Assistance with complex cases. The most complex types of dental claims are TMJ cases and implants. For these claims, the Express Dental Care team consists of clinicians that have five or more years of dental experience. These claims are usually open two months or longer. The care coordinators for these claims, who are the equivalents of an insurance company catastrophic adjuster, have years of experience. They can assist in the determination of the right specialists to bring in and find a conveniently located, qualified professional.
5. Getting the worker to the right specialist, at the right time. Just as with other services, the dental claim is expedited when the injured worker gets prompt access to the right provider needed at each stage in their recovery. However, given the infrequency with which many claims professionals deal with dental claims, this can be difficult. They may not have access to providers in close proximity to the injured worker, or have at their fingertips the appropriate specialist that might be needed.
Express Dental Care expedites dental services for the payer and the injured worker by:
- Coordinating all appointments within 24 hours.
- Calling the claimant to assist in scheduling.
- Obtaining transportation and translation when needed.
- Streamlining the paperwork for the provider, and giving the provider authorization on what they can do at the first appointment so that there are no hidden costs.
The timing of treatment can also be a question that needs resolution. For example, sometimes dental injuries must be treated immediately. In other situations, other injuries require the highest priority, and the dental problems may be addressed after major injuries have healed. In these instances, Express Dental Care assists with the coordination of services as they are needed throughout the continuum of care.
6. Setting Reserves. Just as with other workers’ compensation claims, appropriate reserves must be set for dental injuries, based on the estimation of the services that will be needed through the life of the claim. This determination can be complicated because, as noted, multiple services can be needed from various specialists to repair dental injuries.
Express Dental Care works with adjusters to help them determine the proper reserves, providing a plan of treatment with costs so that appropriate reserve funds can be set aside.
TMJ: Managing the most challenging dental-related condition
TMJ 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 may require bite guards or retainers. To give an idea of how costly these injuries can be to heal, a typical claim for joint replacement, fat grafting, and injections can sometimes exceed $100,000.
Numerous issues are involved in treating TMJ, including:
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Controlling pain and pain management.
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Getting adequate nutrition. If the jaw is not working properly, the patient may be required to adjust or limit their diet to soft foods.
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Impact on daily living; functions like eating, speaking, and talking may be difficult.
- Modified duty may be required.
Treatment options for TMJ may include:
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Heat
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Ibuprofen or other aspirin-like painkillers
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Physical therapy
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Trigger point injections or TENS units
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Surgery may be recommended in some cases
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 the recovery or even require that treatment begin all over again. The complexity of the treatment and the ease of re-injury are the two reasons why these claims can have a long tail.
For TMJ cases, as with other complex dental conditions, Express Dental Care supports the claims professional with a team of highly trained and experienced care coordinators who can provide information and services required to see that the claim is managed appropriately and that clinical services are provided quickly and efficiently.
In summary, dental claims require special handling, clinical oversight, and ongoing management. Finding the right provider or specialist is the first challenge claims adjusters face with a dental claim, followed by providing the time and in-depth expertise to manage the claim through its cycle, which is often considerably longer than other types of therapy. Express Dental Care, as a specialist in workers’ compensation dental injuries and treatment, is a unique resource for claims adjusters and case managers for these often complex cases.
For more information, please contact:
Bill Colacurcio
Phone: 973-316-3718
Email: bill_colacurcio@onecallmedical.com
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