230 Journal of Public Health Dentistry

The Report

This working group identified the parties to a dental plan as five in number: the carrier, the provider. the patient, the employer, and the Insurance Department. Communication between all parties needs to be improved. A carrier of dental insurance should employ a qualified professional consultant, therefore, because the profession needs this input to benefit the carrier’s operations.

Carriers are responsible for review of claims and the initial review of problems. In ad- dition to their professional consultants, carriers require trained claims-personnel. The carrier’s communications on professional judgment must be on a doctor-doctor basis.

The Prudential’s procedure then was reviewed. This Company uses a relatively standard form with the code-numbers printed on the reverse side. Eighty percent of the claims can be processed without professional review. Prudential uses D. I. C. for review of claims.

The carriers indicated that they will use the Pennsylvania Dental Association’s mech- anism of review by peers when their consultants cannot reach an agreement. They pointed out that the architecture of their programs is influenced heavily by the activity of the bar- gaining table and by consideration of costs. The dental profession must recognize these limitations initially but then should advise the carriers how the available dollars should best be spent.

The Association concludes that all programs should provide the basic services and use coinsurance and deductibles when necessary. The Association, further, should establish standards for effective capitation, rather than oppose it outright. A task-force on quality, furthermore, should establish broad criteria that will not hamper the individual dentist.

The two final and formal recommendations of the No. 1 study group are (1) every carrier writing dental coverage should have a dental consultant; and (2) the dental pro- fession should provide input for the buyers of dental insurance in regard to the design of the plan.

VII. The Dentists’ Viewpoint; Report of Workshop No. 2 William Booth, DDS, Chairman*

The Participants Dr. John R. Amsterdam Mr. James D. Bachman Dr. James Bader Dr. Jay Balzer Mr. Robert E. Caffrey Mr. A. Morris Cecil Mr. James W. Chapman Dr. Herbert G. Gebert Mr. C. Donald Hankin

Dr. Joseph J. Hawkins Dr. Bruce T. Mathias Mr. Edward J. Maze Dr. Donne1 M. McHenry Mr. W. F. Myers Dr. Nicholas D. Saccone Mr. Eugene Schloss, Jr. Dr. Marvin Sniderman Mr. Edward R. Thoms

The Report Group No. 2 found it most difficult to define quality. Because of the numerous variables

discussed, a bible on quality could not be written during this working session. Each instance, it was agreed, must be judged individually for establishing quality. The dentists in the group expressed a willingness, however, to work with the carriers to provide more input for specific programs and to help develop a meaningful assessment of quality.

*President-Elect, Pennsylvania Dental Association