Administrative and clinical denials by a large dental insurance provider

The objective of this study was to assess the prevalence and the type of claim denials (administrative, clinical or both) made by a large dental insurance plan. This was a cross-sectional, observational study, which retrospectively collected data from the claims and denial reports of a dental insurance company. The sample consisted of the payment claims submitted by network dentists, based on their procedure reports, reviewed in the third trimester of 2012. The denials were classified and grouped into ‘administrative’, ‘clinical’ or ‘both’. The data were tabulated and submitted to uni- and bivariate analyses. The confidence intervals were 95% and the level of significance was set at 5%. The overall frequency of denials was 8.2% of the total number of procedures performed. The frequency of administrative denials was 72.88%, whereas that of technical denials was 25.95% and that of both, 1.17% (p < 0.05). It was concluded that the overall prevalence of denials in the studied sample was low. Administrative denials were the most prevalent. This type of denial could be reduced if all dental insurance providers had unified clinical and administrative protocols, and if dentists submitted all of the required documentation in accordance with these protocols.

A glosa odontológica em uma operadora de grupo de grande porte / Dental services disallowance in a major health plan provider

Objetivo: verificar a frequência de glosa total e dos procedimentos odontológicos realizados pela rede credenciada de uma operadora de plano de saúde. Materiais e método: trata-se de um trabalho observacional transversal no qual foi realizado um levantamento retrospectivo em uma operadora de grupo exclusivamente odontológica no terceiro trimestre de 2012. A análise quantitativa agrupou os procedimentos baseando-se no rol da Agência Nacional de Saúde Suplementar. Os dados coletados foram tabulados e submetidos a análise estatística com intervalos com 95% de confiança e nível de significância de 5%. Resultados: dos 264.758 procedimentos faturados, 21.716 foram glosados; portanto, o percentual global de glosas em relação ao total de procedimentos foi de 8,20%. A maior frequência de glosas foi observada na radiologia (35,93%), seguida pela dentística (24,04%) e pela prevenção (16,70%). Do total de glosas, a endodontia e a prótese tiveram 4,77% e 2,32%, respectivamente. Entretanto, quando se analisou cada grupo do rol individualmente, 24,37% dos procedimentos da prótese e 22,23% dos procedimentos da endodontia foram glosados. Conclusão: a frequência total de glosa na operadora de plano de saúde foi 8,20%. Os procedimentos mais glosados foram de radiologia, dentística e prevenção. Quando se avaliou a frequência de glosa dentro de um mesmo grupo, a prótese e a endodontia foram as especialidades mais glosadas.

Objective: to observe the frequency of full disallowance and dental procedures performed by an accredited network of a Health Plan Provider. Materials and method: cross-sectional observational study in which we performed a retrospective survey in a group provider for dental care only, in the 3rd quarter of 2012. A quantitative analysis pooled the procedures based on the List of the National Supplementary Health Agency. The collected data were tabulated and subjected to statistical analysis with 95% confidence intervals, and significance level of 5%. Results: from the 264,758 procedures billed, 21,716 were disallowed, so the overall percentage of disallowances over the total number of procedures was 8.20%. The higher frequency of disallowances was seen in radiology (35.93%), followed by dentistry (24.04%), and prevention (16.70%). Endodontics and prosthesis were 4.77% and 2.32% respectively, from the total of disallowances. However, when we individually analyzed each group from the List, 24.37% of the prosthesis procedures, and 22.23% of the endodontic procedures were disallowed. Conclusion: the overall frequency of disallowance in the Health Plan Provider was 8.20%. The most disallowed procedures were radiology, dentistry, and prevention. When the frequency of disallowance within the same group was assessed, prosthesis and endodontics were the most disallowed specialties.