THE READERS' CORNER

1. Do you regularly refer adult patients for a periodontal consultation before treatment, during treatment, or after treatment? If so, what is your rationale? If not, how do you determine when to refer adult patients?

Most of the respondents (83%) said they regularly referred adult patients for a pretreatment periodontal consultation. Only 22% routinely obtained periodontal consultations during treatment, and 18% after treatment.

The principal rationale for the pretreatment consultation was to ensure that the adult patients were disease-free before starting orthodontic treatment. The clinicians also wanted to establish that their patients' oral hygiene and home care were up to the standard required for as long as two years of orthodontics. Several respondents also felt it was important to obtain the periodontist's clearance to proceed with placing appliances. The orthodontists' major concerns included generalized gingivitis, insufficient attached gingival tissue (particularly in the lower anterior region), localized pockets of 5mm or deeper, and generalized bone loss indicative of periodontal disease.

To whom do you normally refer adult patients? What are the most common periodontal problems you encounter in adults?

A periodontist was normally used for referral by 63% of the respondents, while 37% used a general practitioner.

The most common periodontal problem was insufficient attached gingival tissue and recession, mainly in the lower incisor area (mentioned by 60% of the respondents). Other common problems were periodontitis and generalized bone loss (54%), localized pocketing (32%), and pocketing and vertical bone loss subsequent to the loss of molars (18%).

How do you determine when to refer child patients for oral hygiene consultation?

The clinicians clearly felt that generalized inflammation or gingivitis was the most common cause of referral for oral hygiene instruction of children. Most of the practitioners said they would attempt an in-house program of care first, and if this were unsuccessful after two or three visits, they would then refer the patient for an outside consultation.

To whom do you normally refer child patients? What are the most common periodontal problems you encounter in children?

Seventy-eight percent of the respondents usually referred children to a general practitioner, 17% to a periodontist, and 4% to a pediatric dentist.

Generalized gingivitis or inflammation was by far the most commonly encountered problem in children (mentioned by 78% of the respondents). This was followed by insufficient attached gingival tissue or recession (52%) and problems with frenums and their attachments (21%).

Do you believe orthodontic treatment can reduce the possibility of future periodontal problems?

The clinicians strongly believed (96%) that orthodontic treatment can reduce the occurrence of future periodontal problems. Some specific comments:

"I believe that good tooth alignment makes oral hygiene efforts more effective. Also, people with attractive smiles due to orthodontics tend to take more pride in their dental health and are therefore better at oral hygiene."

"I feel that properly aligned teeth in good functional occlusion are very effective in reducing future periodontal problems, as long as the patient maintains this oral hygiene at a level that is nearly plaque-free and continues to care for the teeth with brushing, flossing, and fluoride rinses."

"I believe orthodontic treatment is particularly effective in instances where a single tooth is blocked out labially, causing thinning of the gingiva, and especially if there is traumatic occlusion. Uprighting of abutments and relief of severe crowding may also improve the environment and reduce the likelihood of periodontal disease."

2. What percentage of your active patients have all or part of their orthodontic treatment covered by insurance? For your patients with insurance, what is the average percentage of the treatment fee covered?

A little more than half of the respondents reported that none of their patients had the entire cost of orthodontic treatment covered by insurance. Another 35% said that fewer than 5% of their patients were fully covered, and 10% said that fewer than 10% of their patients were fully covered.

Responses regarding the rate of partial insurance varied widely. One-fourth of the orthodontists reported that 50% of their patients had partial coverage, 23% reported that 33% of their patients had partial coverage, and 17% reported that 80% of their patients had partial coverage.

The most common percentage of partial coverage, reported by a slight majority of respondents, was 33%. A 50% coverage level (sometimes with a $1,000 limit) was reported by 23% of the respondents.

Do you keep a separate log or computer record of patients with insurance coverage?

Nearly two-thirds of the practitioners said they kept no separate records of insurance coverage. Of the 36% who did keep such records, many reported doing so as part of their computerized insurance procedures.

Do you believe insurance coverage brings you patients who might not otherwise have orthodontic treatment?

Fully 98% of the clinicians felt that insurance brought in additional patients. Sixty percent said they accepted assignment of benefits to offer a service to their patients and to ensure that the office received the payments, rather than the patients. The 40% who did not accept assignment of benefits seemed to believe that it was the patient's responsibility to deal with the insurance company and that accepting assignment generated too much paper work.

Do you use an insurance superbill?

Only 18% of the respondents used superbills. Many of the others used forms associated with their in-house computer systems. In fact, 16% had never heard of superbills.

What problems have you encountered in dealing with insurance companies, and how were they resolved?

Many different problems were reported. The most common involved a chronic tendency to make late payments or to look for excuses to delay payments. Another frequently expressed concern was that employees of the insurance companies were unfamiliar with orthodontic problems, were difficult to get responses from, or were generally incompetent. There were also many complaints about insurance companies "losing" forms, requiring copies to be sent to receive payment. Some concern was voiced about insurance companies that continued to request models and x-rays before authorizing payment.

Most offices said they resolved these problems through the persistence of their front-desk staff, by telephoning the insurance companies, and by providing additional copies of paper work.

Do you foresee an increase in problems with insurance?

Of the 60% of the respondents who believed insurance problems would increase, many were worried about companies trying to find new ways to reduce patient benefits, as well as restrictions imposed by closed panels or HMOs on patients' choice of orthodontists.

Specific comments included:

"We keep a separate log through our insurance software program, which can break down payments for insurance and non-insurance patients. This way we know if the insurance has paid the full amount."

"For our log, our computer generates: ID number, patient name, billing name, insurance company, insurance coverage, insurance balance, insurance months left vs. treatment months, percentage of treatment completed vs. percentage of fee received, date of last insurance receipt, and amount of last receipt for each patient with insurance coverage."

"We accept assignment, as we would rather have the patient or parent sign an agreement with us. That way we avoid delays, and there is no confusion as to who is responsible for the outstanding balance if fringe benefit cutbacks or layoffs occur."

"We accept assignment because ideally we would like to receive 20-25% of the treatment fee at the banding appointment. Insurance's initial fee combined with our patient's initial fee brings us closer to that desired amount. It is also easier to get separated families' payments when insurance benefits are assigned directly to our office."

"We prefer not to accept assignment, but in some cases the insurance company will pay only to the provider. Our reasons for not accepting assignment include tracking problems, time consumed being the middle man, and dealing with a situation that really is the responsibility of the patient."

"Originally I did not accept assignment. This was difficult to explain to patients because the MDs and hospitals would accept assignment. Also, we have a high divorce rate and with separated parents, they might keep the money."

"Orthodontists in our area have been working as a group together with the insurance companies, and we have a reasonable relationship. We collect post-dated checks from our patient, prior to treatment, and the patient presents receipts monthly to the insurance company."

"Hopefully, electronic submission will in the future reduce human error at the insurance companies."

"I see big problems ahead with managed care. I call this the silent erosion of the patient pool--the patients we never knew we lost because they were sent directly to the participating HMO orthodontist."

"Orthodontic benefits are now including payments made for extractions and for surgical exposure of impacted cuspids. This is not fair!"

JCO would like to thank the following contributors to this month's column:

Dr. Peter J. Abell, Brattleboro, VT

Dr. Dean E. Albertson, Owosso, MI

Dr. Jeffrey I. Berger, Torrance, CA

Dr. James A. Bond, Chalfont, PA

Dr. Cramer L. Boswell, Abingdon, VA

Dr. Philip B. Caldwell, Duncanville, TX

Dr. Douglas L. Cameron, Jr., Bellevue, WA

Dr. Robert C. Chiappone, Concord, CA

Drs. Norman L. Chmielewski and John W. Randall, Bay City, MI

Drs. William J. Clauss, William A. Heisel, J. Daniel Kutt, and Mark Stephen Hunter, Wyandotte, MI

Dr. Betty L. Cragg, Unionville, Ontario

Dr. Alexander Dell, Houston, TX

Dr. Ralph Depee, Pampa, TX

Dr. Mark Detrick, El Toro, CA

Dr. Olwyn Diamond, Baltimore, MD

Dr. John A. Dorsch, Kansas City, MO

Dr. John J. Flowers, Jr., Dothan, AL

Dr. Donald W. Frantz, Old Bridge, NJ

Dr. William J. Glenos, Jr., St. Augustine, FL

Dr. Stephen L. Gold, Pinole, CA

Dr. J.L. Goldsmith Rabinovich, Mexico City, Mexico

Drs. Alfred C. Griffin, Jr., and Scott C. Berman, Warrenton, VA

Dr. Marshall B. Grunwald, Elmhurst, IL

Dr. Henry S. Hammer, Kailua, HI

Dr. Jeffrey H. Harnett, East Northport, NY

Dr. Ronald G. Heiber, Lancaster, OH

Dr. Kenneth Kapley, Solon, OH

Dr. Jeff G. Keeling, Lubbock, TX

Dr. Iris Kivity-Chandler, Toronto, Ontario

Dr. Hermann K. Lee, Winnipeg, Manitoba

Dr. Mark K. McAlister, Idaho Falls, ID

Dr. Mark T. Moore, Jamestown, NC

Dr. Jan A. Olenginski, Wilkes Barre, PA

Dr. Timothy R. Pearson, Walnut Creek, CA

Dr. Mark A. Price, Hollidaysburg, PA

Dr. William R. Proffit, Chapel Hill, NC

Dr. Paul T. Rasmussen, Schenectady, NY

Dr. Robert E. Rosenblum, Canandaigua, NY

Dr. Lawrence N. Rouff, Binghamton, NY

Dr. Jon J. Sisulak, Hales Corners, WI

Dr. Francis G.A. Solga, Schuylkill Haven, PA

Dr. Stanley Starr, Medfield, MA