Workers' comp cases too complicated? Try this

A pizza delivery guy who gets punched in the mouth during a robbery. A UPS driver who is hit in the face with falling boxes. A farmer kicked by a horse. An amusement park worker playing Spiderman who couldn't quite stick to the wall.

What do these people have in common? They all experienced workplace-related dental injuries that were covered by workers' compensation. But finding a dentist to treat them was a challenge for insurance companies handling such claims.

Dentists have shied away from workers' comp cases because of low reimbursement rates and the complicated claims process. But now there's a company that works with insurance companies and guarantees payment to dentists while also streamlining the paperwork. And now thousands of dentists across the U.S. have signed up to treat such cases.

"Insurance companies were saying that it's hard to find dentists who would accept workers' comp cases," Stacey Whidden, CEO of Express Dental Care, explained to DrBicuspid.com. "And dentists complained about low reimbursements and the amount of paperwork. It took a lot of convincing because they had bad experiences with workers' comp."

The 10-year-old company handled more than 29,000 dental claims last year using 16,000 dentists in its network. The injuries run the gamut: In addition to pizza delivery people who get punched during robberies and farmers who get kicked in the teeth by a skittish animal, Express Dental Care has seen claims for mechanics hit with wrenches, hockey players hit by pucks, baseball players hit by bats or balls, roofers, construction workers, and migrant workers injured by farm equipment or falling branches.

"We've had a lot of UPS and FedEx drivers who fell or had boxes hit them in the face," Whidden said. "The amusement park cases are always funny."

Express Dental Care connects insurance companies with the dentists in its network, then helps clinically manage the cases.

"We tell dentists what forms to fill out, and we help with the paperwork," Whidden explained. Each state has different forms, she noted; some, like Florida, change theirs every year.

The company also removes the doubt about reimbursements, confirming in advance just how much dentists will be paid for their services.

"We let them know what the reimbursement will be so they're guaranteed payment of the procedures approved," she noted. "We take the risk that the insurance company will pay."

Some states have workers' comp fee schedules, but many don't, Whidden pointed out.

"Many dentists don't understand workers' comp," she said, "so it was miscommunication between both the dentists and the insurance companies."

How it works

Express Dental Care schedules an appointment with a dentist who does the evaluation and submits a treatment plan that is analyzed to ensure the work will be covered by the insurance company. The company also advises dentists on dental notes that may be required to document the injury and substantiate the claim.

"Dentists want to treat the whole mouth," Whidden said. "But if the items aren't related to work injuries, like if they have cavities that are nowhere near the dental trauma, then the worker has to pay for those himself."

Participating dentists say the referrals have helped build their practices because the patients often become regular clients. And in the current bad economy, many are finding that it's a way to fill otherwise empty chairs.

Whidden's company helps insurance companies understand why the same injury can cost different amounts. "They would get an $800 bill for a chipped tooth, then the next day they'd get a $1,500 bill for the same thing, and they didn't understand why," Whidden said.

Sometimes dental work is needed before other injuries can be treated. One worker couldn't have knee surgery because he had an oral infection that had to be cleared up before he could get anesthesia, Whidden recalled.

Other cases require specialists such as endodontists and maxillofacial surgeons, and the company has to explain and justify their treatments. "We have to go back and forth between specialists and explain that you have to wait for bone grafts to heal before putting in implants," she pointed out.

The cases also differ due to the worker's prior dental history. "If a young person slips and chips their tooth, it's simple because they have good bone structure, and they're usually in good dental health," Whidden explained. "But if the injured worker hasn't been to the dentist in 10 years, they may have perio disease, gingivitis, or poor bone structure so it's not going to be a simple crown. Sometimes it's so much more that's needed."

When migrant workers get hurt, the paperwork gets complicated because they often move from the state where they were injured to other states while following the harvest.

Prices also vary depending on geographic location: Bills will be more in New York City or San Francisco than Des Moines, IA, for example, Whidden said.

"Injured workers just want to be treated and have their mouth restored," she said, "and they deserve good care."