Rules of Reimbursement

Dental hygienists working in settings outside of the traditional private practice have been able to garner support for years—if they were willing to give away their services and only treat patients who no one else wanted to serve. This is changing. Access-to-care issues are driving an increase in practice settings, decreased supervision, and the ability to receive payment for dental hygiene services.

Cindy Mann, JD, director of the Center for Medicaid and Children’s Health Insurance Program Services, released an informational bulletin on July 10, 2014.¹ The bulletin was intended to support states in their efforts to improve the delivery of oral health services. It clearly states that, according to federal requirements, dental hygienists can be directly paid for services whether working under supervision, working in collaboration with a dental or medical provider, or practicing independently. It is up to states to allow dental hygienists to enroll as Medicaid providers, and many have.

The starting point for direct reimbursement begins with a national provider identifier (NPI) number. All dental hygienists should have a NPI number, regardless of whether they are currently filing claims, so they are recognized as primary care providers. When seeking reimbursement, there are different payers to consider: Medicaid, private insurance/managed care, and private-pay individuals. In order to bill for services, dental hygienists must remain up-to-date on the current dental terminology (CDT) codes and what services are allowed through their state statute and regulations.

PAYER SOURCES

Dental hygienists must determine if their state allows for registration as Medicaid providers. If so, they can enroll and, upon approval, start billing and collecting payment for services rendered. In states that dental hygienists are not allowed to become Medicaid providers, they will need to affiliate with a professional who is a Medicaid provider. A group Medicaid number can then be applied for, listing the professional with the Medicaid number as an employee and/or part of the group business/practice. All claims will use the affiliate’s number under the “treating dentist” section of the claim form. The group/business number and information will be entered under the “billing dentist or dental entity” section of the claim form. This ensures the payment is delivered to the business entity. It also keeps the income from being considered taxable to the affiliated employee and, instead, is taxable income for the group/business.

Private insurers have different rules regarding who can become a provider within their system. Dental hygienists will need to check with each company about its policy. They may need to submit a letter asking to become a provider and explaining the statute and regulations that dictate how, when, and where they practice. Many insurance companies are now paying dental hygienists for their services utilizing their NPI numbers. If the insurance company is not directly reimbursing dental hygienists, the claim will need to be filed in the same format as the aforementioned Medicaid claim by using a business affiliate.

Private-pay clients have much more freedom to work with any provider they wish for the services they choose to receive. Dental hygienists must obtain a signed consent for treatment that clearly indicates the services that will be provided and that the patient and/or parent or guardian is responsible for payment.

In settings such as nursing homes, assisted living facilities, long-term care facilities, and hospitals, dental hygienists may be paid directly by the facility through recurring fees charged to the patient’s caretakers. Clinicians may need to initiate an agreement with the facility so they can contact the patient’s representative who is financially responsible for his or her care. This needs to be done regardless of the payer in most settings, so that permission to treat and to bill can be acquired.

CODING CHALLENGES

The American Dental Association CDT codes are limited when it comes to services delivered by dental hygienists. Strides are being made, however, to create new CDT codes and to revise many of the outdated ones. The American Dental Hygienists’ Association has been testifying for years to bring about change. In 2013, two new CDT codes were added to address occasions when a comprehensive dental exam is not conducted by a dentist—D0190 (screening of a patient) and D0191 (assessment of a patient). Reimbursement has already been adopted in more than 16 states for these codes. In 2014, three additional codes were added to the CDT dealing with caries risk assessment: D0161 (caries risk assessment and documentation finding of low risk); D0162 (caries risk assessment and documentation finding of medium risk); and D0163 (caries risk assessment and documentation finding of high risk). While all payers may not reimburse these codes at this time, they must be utilized to bring legitimacy to claims and the services provided.

Direct reimbursement has come a long way. Our professional association advocates at the state and federal levels to bring about change. Dental hygienists should be grateful for the pioneers who forged the path ahead. As the profession becomes more integrated in the interdisciplinary health care team, direct reimbursement for dental hygiene services will become more common.

From Perspectives on Dental Hygiene, a supplement to Dimensions of Dental Hygiene. November 2014;12(11):24–25.