Managing Dental Claims in Workers Comp

 
 

Dental injuries may be less common than other types of workers compensation cases, but these claims present significant challenges, complications and costs. Given the infrequency with which these injuries occur, many claims professionals have limited knowledge of dental terminology, coding and billing procedures. And many organizations lack protocols and guidelines on how to mange these claims. Unlike other types of services, such as X-rays or MRIs, which may only be required once or twice during the life of a claim, the average dental claim requires 17 dental provider visits.

Any trauma that impacts an employee from the neck up is likely to involve a dental injury. For example, dental trauma may occur as a result of car accidents, workplace violence, construction or manufacturing accidents, slips and falls, or falling objects. If dental claims are not properly managed, they can hurt the claim’s outcome, delaying the injured worker’s recovery and adding unnecessary — and usually hefty — costs.

Risk managers historically have relied on traditional preferred provider organizations (PPOs) to treat dental injuries, but these claims require a more specialized approach. Risk managers must be sure that their network is leveraging dental management strategies to manage costs and avoid unnecessary services.

Finding a dentist who has experience in workers compensation and coordinating the right specialists are important, but dental injuries also require in-depth clinical expertise to manage claims throughout their life cycle. Risk managers must consider the following guidelines to ensure their provider network will properly manage dental claims.
 
Locating Dentists
Traditional workers compensation networks have not focused on recruiting dentists. Finding a dentist who understands and is willing to work within the workers comp system can be challenging. A network should not only recruit dentists but also help them navigate the system with appropriate forms and procedures. With this guidance, dentists are more likely to accept work-related injury referrals.

Appropriate Dental Treatment
By nature, dentists are accustomed to treating the whole mouth, which can drive up costs when services treat ailments unrelated to the injury the claim is intended to cover. For example, an injured worker may have a chipped tooth, but a payer may receive a $20,000 bill because the dentist also charged them for the treatment of four cavities, periodontal disease and gingivitis. Dentists who participate in a specialized workers compensation network will perform a prospective oral evaluation to determine what is billable in relation to the work-related injury. These dentists also present an injury-related dental care plan, which claims adjusters or nurse case managers can review and approve.

Dental Specialists
There are many types of dental specialists, including periodontists, endodontists and oral maxillofacial surgeons. So it may be difficult for claims professionals to determine when specialists are required. A provider network must have in-house clinical expertise to help make appropriate dental referrals and coordinate dental care so injured workers receive the right treatment from the right specialist at the right time.

Clinical Support
Dental claims often require clinical oversight. A network should have a clinical team with the expertise to handle various types and levels of dental claims complexity. A simple chipped tooth or filling, for example, can be handled in one or two dental visits, whereas a case that requires oral surgery may be open for several months and require the additional services of various specialists. If the treatment plan is complicated, the clinical team will coordinate various specialist providers.

Complex Cases
Complex dental claims require a clinical team consisting of care coordinators and clinicians who have years of dental experience. For example, imagine a box falls on a delivery driver and hits him in the mouth. He complains of jaw pain and a loose tooth. He has not seen a dentist in two years and has a history of periodontal disease. The clinical team will recognize that while the payer is not liable for the entire dental history, the infection must be sufficiently cleared up before the injury-specific dental care can occur. Otherwise, future complications may result.

Dental Reserves
Determining appropriate reserves for dental claims is complicated. A network should provide clinical knowledge of dental procedures and pricing, and work with adjusters to set appropriate reserves. If the network presents a treatment plan, this will help adjusters estimate costs so proper funds can be set aside.

The Dreaded TMJ Cases
Temporomandibular joint (TMJ) disorder can be triggered by impact to the jaw or post-traumatic stress that leads to grinding of the teeth and jaw. This disorder is one of the most costly dental injuries. Treatment ranges from injections to relax jaw muscles to complete joint replacement, which can easily exceed $100,000 in costs. Another challenge is that additional stress or a secondary bump to the jaw can set recovery back and require treatment to start over. For such complex dental conditions, a network must provide clinical oversight to ensure claims are optimally managed.

 

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About the Author

Laura McLain, RN, is the director of clinical services at Express Dental Care.

 
 

12 Comments

  • Very nice step by step with lots of good information. You got it all covered, nothing really to add. I never really heard of anybody hurting their teeth at work… How does that happen?

     
  • Jessica P.

    Me neither. Unfortunately, I can now give one way, my husband is a Mason and slipped off a 3 foot jack board (lifted scaffolding) when it gave slightly. While he was falling, he hit a pile of loose brick with his hand. Possibly trying to catch himself? When he landed the loose brick slammed him in the face, breaking one tooth completely in half and majorly cracking another. He has seen an approved dentist for evaluation only and now we are in limbo. The worker's comp people have requested his previous dental records, to rule out any previous conditions. In the mean time he is living in pain.

     
    • Highly recommend this dental office in Brooklyn, NY. It is called Modern Dentistry on Ocean Avenue and they accept workers compensation cases.

       
  • About "Managing Dental Claims in Workers Comp" whatever you have shared here seems to me sound handy and very wise allocation and through reading out this input I've come to know how manage dental claims in workers comp. Thanks

     
  • yes please explain how some can hurt their teeth at work? what in gods name was he doing?

     
  • If you work in the field of Corrections its easy to happen. You can injure your teeth while responding to a fight between inmates. That would fall under workers comp because you were working and responding to your duties as a C.O

     
  • Pieter

    Crank starting an old pump engine, crank hit employee on the mouth breaking 3 teeth…..

     
  • Michele

    As someone that has damaged her mouth at work, I appreciate this information. For those wondering how it could happen… Have you ever took a corner too fast and slammed your shoulder? Well as you turn and move your head at the same time, you can lead with your head instead of your shoulder. I smashed my mouth into a metal door frame as I was stopping to ask a coworker something. I lost one tooth and my front teeth are still not stable and it’s been 6mos.

     
  • andrew .R

    Damaged teeth happens at work …. 2 weeks ago I was laying under a truck with a large 2 inch wrench , it slipped and I snapped 2 teeth at the root , I am curious though if anyone knows where to find perm disfigure chart associated with dental damage

     
  • I got inured on a boom lift. Im an electrican. In ohio where exactly can i find a dental practice that takes workerscompt, along with orthopedic care, seeings how none of my bottom teeth will now be straight

     
  • debbie

    Ohhh it can happen!!! when you fall down a flight of stairs… come on its easy for me to imagine a work injurie like that.

     
  • Tammy

    If you are reading this and have had an Injury such as a fall and the spine is involved you more than likely have had to take numerous medications over the years. As a result of all the medication due to the injury you will likely develop a condition called Xerostomia. This is dry mouth syndrome which limits the saliva and thus results in decay in the teeth. Workers Compensation will be liable for your dental work in that situation. Tammy

     
 

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