Benefit Design and Reimbursement Considerations for Teledentistry

Nathan Suter, DDS

ABSTRACT

Teledentistry is a broad term that allows for patient care to be digitized and delivered through multiple modalities. Teledentistry can be facilitated via many innovative technologies, thus allowing patients to engage in dental care regardless of physical and structural constraints of the dentist’s availability, creating equity through the availability of auxiliary dental team members. This manuscript lays out some of the ways that policymakers and payers can facilitate a digital transformation of care and allow teledentistry to enhance the way dental practitioners can develop systems of care for both today and the future of dentistry.

Keywords: Teledentistry, dental insurance, dental benefits

Teledentistry is a broad term that allows for patient care to be digitized and delivered through multiple modalities. Teledentistry can be facilitated via many innovative technologies, thus allowing patients to engage in dental care regardless of physical and structural constraints of the dentist’s availability, creating equity through the availability of auxiliary dental team members.

This manuscript explores some of the ways that policymakers and payers can facilitate a digital transformation of care and allow teledentistry to enhance the way dental practitioners can develop systems of care for both today and the future of dentistry.

Providers have used teledentistry to deliver care to the most vulnerable and underserved patients, both rural and urban, for more than a decade. This initial concept was illustrated with success in California by the University of the Pacific, Arthur A Dugoni Dental School’s virtual dental home model. [1]

The initial success in California was replicated in many states prior to the pandemic in a model utilizing dental hygienists to send data to be reviewed by a dentist for remote diagnosis and treatment planning. In many states, teledentistry was not allowed as a reimbursable service, which limited the utilization among providers to implement this model of care.

During the COVID-19 outbreak, many states changed scope-of-practice guidelines to allow the reimbursement and utilization of teledentistry, seeing it as an effective way to assess and triage patients while limiting in-office visits except for those in need of urgent or emergency care. One issue facing both patients and their potential dental home are stop-gap partnerships with dental insurance companies and national teledentistry mobile platforms that were announced during the pandemic. 2 Many insurance companies quickly partnered 3 with national teledentistry companies to provide near on-demand dental consults between a patient and a dentist who is licensed in multiple states. The insurance companies found a way to make their products relevant and accessible to employers and their employees during the pandemic. However, the dilemma is that these teledentistry visits often require the copay to be met and count as one of the oral evaluations a patient or member may use in a calendar year, unlike 24-hour nurse lines or telehealth visits in a major health insurance plan.

Through these services, a patient gets access to dental care that is very limited in what services may be provided. In most cases, a referral and an antibiotic prescription can be provided. These teleprovider visits can often be a detour to care that sometimes refers patients to a dentist who is in network. Continuity of care would be delivered in a more holistic way if the direct-to-consumer options were an additional benefit outside the members’ plan or if the teledentistry visit was delivered by the treating dental provider.

Over the course of the pandemic, there has been a surge in utilization of teledentistry. The American Dental Association (ADA) Health Policy Institute (HPI) surveyed providers and found initially that providers quickly adopted the ability to remotely triage their patients, but remote triaging waned as offices started to open again. 4 A follow-up survey done by HPI revealed that while teledentistry triage declined from 24% in April 2020 to 12% by July 2020, dentists were providing a number of other services via teledentistry (FIGURE 1). In a February 2021 survey, 5 HPI delved deeper into teledentistry adoption and found that over 36% of private practice dentists and over 60% of public health dentists were using some form of teledentistry in their practices (FIGURE 2). The application of teledentistry was broad and included triage, consults, postop, aligner checks, hygiene recall, patient education and more.

Based on the rapid increase in teledentistry utilization, it is very important that the profession revisit how and when a provider is reimbursed for teledentistry services. The existing structure for reimbursement is exclusively based on procedures or services provided in person by a dentist or a dental hygienist. Many valuable services can be rendered remotely by a provider. The entire dental industry will have to be motivated to make this type of system change. Many providers will only change their clinical workflow when they see reimbursement change from insurance benefit plans. 6,7 These services can be convenient for a patient as well as delegated to an allied team member under appropriate credentials and supervision. In a time when many states are increasing the number of citizens enrolled in expanded Medicaid as well as the possible addition of dental benefits to Medicare, we should revisit how the dental industry can meet all of this demand. Part of the solution is through teledentistry and the digitization of dental care.

Four Pillars of Teledentistry Reimbursement

In order to understand how teledentistry can be properly funded by both policymakers and insurance companies, the dental industry can learn a lot from the medical industry. Teledentistry fits under the umbrella of telehealth, which includes professions like dermatology, post-acute care, cardiology, pulmonology and others that have similar challenges and have offered telemedicine for over a decade. Telehealth (including teledentistry) reimbursement is currently broken down into four components, which many states or insurance companies decide and include in their policies.

One: Service

The list of services that can be delivered via teledentistry usually includes diagnostic services such as limited, comprehensive and periodic oral evaluations as well as imaging captured through either radiographs or photographs. The location of the patient usually determines the level of diagnostic data that is available for the services to be delivered. For example, a patient at home using a secured videoconference tool may only receive a consultation or limited exam, while a patient seen in a clinical setting may have a full scope of diagnostic images and radiographs captured that allows a dentist to complete a more thorough evaluation. As technology advances, it is important to revisit the services that are covered by policies and dental plans. We can learn from our medical peers and see that the use of connected devices can allow for a new way to reach, educate, intervene and create targeted treatment plans for patients’ specific needs.

Two: Location

For decades, telehealth has had a location component tied to reimbursement. In many policies, a list of approved sites or facility types have dictated when a service can be reimbursed. This component is still in place in many state and federal policies. However, modern alternatives are emerging with the significant change in technology and because a point-to-point connection of a “secure” line is not needed with modern hardware and software due to new ways to encrypt data and communicate with mobile devices. An example of location reimbursement restrictions would be that for years a provider office to a hospital was reimbursable, but in many states, a provider’s office to a patient’s home was not reimbursable. Many states temporarily enacted workarounds due to the pandemic, and a more holistic and permanent solution needs to be enacted.

Three: Modality

Telehealth service can be delivered in multiple ways. Two mainstream categories, or modalities, are billable for teledentistry services. The ADA has updated guidance on these two modalities based on its current policy toward teledentistry. 8 The modality relates to how a provider engages in the care of the patient.

Synchronous or ‘Real Time’

Synchronous refers to video communication between a patient and a provider happening in real time. In many situations, the patient is accompanied by a provider such as a dental assistant or dental hygienist. Patients and providers may communicate directly using a smartphone or computer with videoconferencing software. Synchronous is usually what most patients and even providers imagine when first hearing about teledentistry. This is a common starting point, but one-on-one interactive modality limits the potential impact that other modalities and technologies can provide. This form of teledentistry still requires the provider and the patient to align their availability and creates a potential bottleneck to reaching preventive and diagnostic services.

Asynchronous or ‘Store and Forward’

Asynchronous is the transmission of images and/or data taken at a separate time from when the assessment or initial visit took place. This can be facilitated with a digital health form. Data may be stored directly into an existing practice management or electronic dental record to review at a later time when the provider is available. How data is collected is changing as technology improves. Many dental offices have added digital forms and ways to send images directly from the patient, and depending on the data collected, this can be enough for a limiteduse case. The transmission of data, notes and images from hygienist to dentist was the most common form of teledentistry prior to the pandemic, mainly for public health settings. Another area of growing interest is the ability of patient monitoring and how data can be sent directly to a dentist to provide services to patients.

Four: Provider

The last pillar of telehealth policy and plans is the specific list of providers who can provide services and submit claims for reimbursement. This is usually a state-by-state law, regulation or rule. States typically add dentist, hygienist, oral surgeon, dental assistant and others to a list that includes all health care providers under overarching telehealth legislation. Many states during the pandemic added dentists and hygienists temporarily, due to executive orders. Stakeholders should review any provider list and ensure that oral health care providers are represented in any permanent telehealth legislation or regulations.

An additional regulatory aspect of telehealth is each state’s dental or dental hygiene practice act. Dental boards have the responsibility to maintain patient safety through enforcement and oversight of regulations and standards of care. Teledentistry requires the same standard of care as in-person care. Technology allows for some of that care to be digitized and delivered in new and innovative ways.

A state dental board has an influence on all of the pillars of teledentistry. The burden of the dental boards is to create regulations that allow for patient safety without unnecessary restrictions, limiting access to care or restrictions that become obsolete as the technology improves.

Benefit Considerations

Coding and submitting for teledentistry is as important to dental insurance companies and state governments as it is for dentists. Many states, including California, made adjustments to their reimbursement models in response to the pandemic. 9 Historically, teledentistry is a process of providing current diagnostic procedure codes using technology. The teledentistry codes for synchronous (D9995) and asynchronous (D9996) are generally used in order to label the visit as a telehealth encounter. These codes are completed in conjunction with the initial diagnostic procedure code. An example would be when a dental hygienist is collecting diagnostic data and forwards it to a dentist or when a dentist is providing a live consultation with a patient. A few state Medicaid agencies 10,11 and insurance companies have provided an additional benefit for the adjunctive teledentistry visit codes in addition to the preventive and diagnostic codes.

Many states, including California, made adjustments to their reimbursement models in response to the pandemic.

Going forward, the industry should consider how technology could enhance new ways to see patients and expand the utilization of oral health in new ways focused on earlier interventions. There are some additional use cases that need to be researched by insurance carriers and implemented as teledentistry allows for innovative ways to care for patients.

The ‘Digital Front Door’

Telehealth, including teledentistry, saw a 38x increase in adoption and has been sustained at that level year over year from February 2020 to 2021. 12 There is a significant increase in these new ways to access care through what is being called the “digital front door.” Medical insurance companies are even creating plans that exclusively start with a virtual or near-virtual visit. The potential here is a more efficient way to both triage care and deliver preventive care. Some of the issues of dental insurance companies’ initial offerings for teledentistry are important but could be improved in at least a couple of ways:

■ Offer in-network dentists a platform that allows patients searching for a dentist via teledentistry to connect directly with the treating dentist and team. This would require a significant number of network dentists to adopt teledentistry referrals as well as an upgrade from the traditional “directory” of network providers that a patient uses to search for a dentist near them.

■ Change these virtual-only third-party consults from national teledentistry platforms to an added benefit that would not count as one of the annual examination benefits and not require a copay. This is essentially what medical plans have offered for almost a decade to help triage care. The current system for these third-party teledentistry providers is causing confusion for the patient and the network provider when the patient finds a dental home and is needing diagnostics in addition to treatment.

Risk Stratification of Care Through Teledentistry

Risk stratification is a medical term for a standard process of assigning all patients in a practice a particular risk status. In a traditional dental practice, every patient with a recall visit is seen by the dentist in person along with the patients in treatment throughout the day. The dentist is ultimately the “gatekeeper of care.” If a practice offers hygiene care under general supervision, it can remedy some of this bottleneck. If payers and providers would begin to risk stratify their patients, teledentistry may offer a more sustainable delivery model. The dentist in the traditional practice has to interrupt their treatment appointments in order to check all of the hygiene patients regardless if they are a high-risk or a low-risk patient. With risk stratification, all low- and even moderate-risk patients could see the hygienist. These lower-risk patients can receive all preventive care, diagnostic records and an asynchronous teledentistry visit. This can free the practice to offer more convenient hours for care outside of the dentist’s schedule while also offering shorter hygiene visits. 13 In a practice that adopts this model, a dentist could increase the capacity of the schedule and focus on quality of treatment by only seeing treatment patients and high-risk patients in person while reviewing the patient records for the low- or moderate-risk patients through teledentistry recall visits.

Teledentistry Enabled Provider to Provider Consultations

The traditional patient referral from a general dentist to a specialist is a piece of paper or online form submission to a nearby dental specialist. These patient referrals can be very dependent on the patient’s own follow-through, and the general dentist and team have no direct incentive to coordinate the care of the patient. Some primary care doctors are incentivized to close the “referral loop” through contracts with some government and insurance companies. 14 These types of visits are sometimes called eConsults and have seen positive findings by both patients and providers, although the relationship with the general practitioner is noted as a key to a successful referral via eConsult. 15 Dental insurance companies would need to either add new codes to their covered benefits, such as D9310 Consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment) or incentivize a digitally enhanced method of teledentistry and care coordination. If these types of benefits are not added, there will not be an incentive to encourage a business decision to invest in new technology or workflows.

Patient Monitoring

The final piece of the teledentistry puzzle is the growing area of patient monitoring through connected health care devices or applications. The majority of these services have not seen the adoption in dentistry as they have in medicine. Devices like wearable devices, smartphones and tablets have facilitated a growth in patient monitoring in telehealth. In dentistry, there is earlystage research in areas of connected toothbrushes, mobile device cameras, pH monitoring, sleep monitoring, microbiome testing and more. Recent financial success like French company Dental Monitoring getting a valuation of over $1 billion shows that some of these companies are showing value for orthodontists and dentists for even nonbillable visits like monitoring the progression of orthodontic cases. 16 Patient monitoring in dentistry has the potential to learn from the medical industry that has made patient monitoring work for multiple specialties through multiple different technologies. In medicine, this has added value for preventive care compliance, postoperative follow-up, patient education and early interventions. 17 A dental practice with patients utilizing connected devices could allow a dentist and the rest of the care team to maintain more patients at a lower cost while focusing the dentist’s time on higher-need patients needing surgical interventions.

Some primary care doctors are incentivized to close the “referral loop” through contracts with some government and insurance companies.

Summary

The health care industry is in a period of transformation due to the COVID-19 pandemic, and there has been an increase in demand and adoption for a more digitized delivery of care. 18 Dentistry has a pre-pandemic history of utilizing teledentistry to deliver care in innovative ways. The pandemic has brought heightened interest and opportunity for patients, providers and payers. There are many opportunities to adopt these new technologies and incorporate them into the practice of dentistry. The burden is on both providers and insurance carriers to facilitate the transformation that is taking place. This can be through state and federal policymaking, educating members/patients on the value of teledentistry, investing in the modernization of dental practices, training teledentistry in continuing education and academic settings and adjusting reimbursement models. As technology advances, many of these new systems will have to adapt. The way health care is being delivered is changing rapidly, and it will take the entire dental industry to meet this challenge.

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