Predetermination as a Cost-containment Mechanism in a Social Allowances Dental Program in Manitoba

Autor: Peter Cooney, T. H. Hassard, Ulla A. Spangen
Rok vydání: 1995
Předmět:
Zdroj: Journal of Public Health Dentistry. 55:177-180
ISSN: 1752-7325
0022-4006
DOI: 10.1111/j.1752-7325.1995.tb02363.x
Popis: Objectives: A review of dental consultant actions during predetermination of benefits in the publicly insured indemnity program in Manitoba under which Social Allowances Health Services certificate holders receive dental care was under-taken to determine the value of this process as a cost-containment mechanism. Methods: Dollar amounts of services denied by a dental consultant during eight predetermination sessions selected to represent the 96 sessions during the 1990–91 fiscal year were determined and grouped according to category of service. Results: Approximately one-third of average total expenditures each month were reviewed by the dental consultant through the predetermination process. Of the requested dollar amount reviewed, 26 percent was denied, a savings of 8.5 percent of average total monthly expenditures. The categories of services that made up the denied requests were: prosthodontics (30%); endodontics (32%); restorative (5%); periodontics (12%); and miscellaneous (21%), including diagnostic, surgical, preventive, orthodontic, and adjunctive. Conclusions: A properly administered predetermination process can save a third party 8.5 percent of total plan expenditures; dollar changes to altered treatment plans amount to a 26 percent reduction of expenditures relating to these requests. A predetermination process with an unbiased appeal mechanism provides a system to advise and protect providers regarding what treatment is covered.
Databáze: OpenAIRE
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