But of an estimated 18,000 registered dental hygienists in Canada, only a small percentage currently practise independently. Last year, Ontario and Nova Scotia followed the West and granted their hygienists independent practice. But only time will tell if the addition of these provinces will cause more hygienists to go it alone. Still, whether five or 500 more hygienists go solo, employers need to know what kind of impact this legislation will have on their dental plans.
We’ve Got You Covered
Presently, most insurance contracts state that dental hygiene services must be provided under the supervision of a dentist in order for a claimant to be reimbursed. But as more provinces are beginning to lift the restriction to independent practice, these older contracts…well, just don’t have any bite.
Insurers are reviewing their contracts as a result. Green Shield Canada, for example, accepts claims, but with a twist. It puts the onus on employers to decide if they want independent hygienists under their coverage. “If a plan sponsor wants to include services provided by that practitioner, that’s an informed decision that they make,” says Steve Moffatt, vice-president, sales and marketing, Green Shield Canada. “We do not include it as a standard feature in all of our plans.” Manulife Financial is taking a similar approach, accepting claims on employer request, and is currently reviewing the wording of its contracts. Sun Life Financial and Great-West Life accept independent hygienist claims on a standard basis.
It’s All in the Communication
But whatever approach an insurer takes, it must communicate its policies to employers. Green Shield included a bulletin in its January 2008 newsletter to inform Ontario employers of independent practice for hygienists. Great-West Life is advising its clients through print and electronic notices. Of course, employees need to be informed, too. “From an employer’s perspective, if you have not made a decision and your [insurance] carrier does not automatically recognize the category, and an employee incurs a claim and the claim is denied, you’re going to have an issue to deal with,” says John Tompkins, principal and senior benefits consultant, with Hewitt Associates, in Toronto. Case in point: Green Shield. “We received a few claims in December,” says Moffatt. “However, those claims were denied, as the hygienist wasn’t part of the client offering.”
Numbers Game
At this point, however, the number of claims is minimal. “Looking to the experience in the western provinces—where the number of dental hygienists practicing independently is very low—the number of claims we’ve seen is very small,” says Terry Martin, senior product management consultant, group benefits, Sun Life Financial. Since 2005, Sun Life has had an average of five to 10 claims per month. Green Shield didn’t pay out any hygienist claims in 2007, and had only nine the year before. “You can see it’s not a big thing at this point,” says Moffatt.
The impact on the cost of benefits and the savings for employers would also be minimal. “Regardless of where the service would be performed,” says Martin, “most plans will have certain limits of scaling and polishing. Even if [the claim] was coming in from an independent hygienist, those limits would still apply.” “The experience in B.C. shows that there’s a savings in the magnitude of around 1%,” says Tompkins. This suggests, he says, that the hygienists’ fees aren’t much different than the current Canadian Dental Association (CDA) fee guide.
But why would an employee head to a hygiene clinic if he or she can see the dentist and the hygienist in one appointment? Tompkins doesn’t see the “behaviour incentive.” “From a consumer point of view, I’m not sure where the value-add is.” That value-add may not be prevalent in urban centres, where dentists and hygienists are as rampant as cavities, but it’s a different situation in Canada’s rural communities. Take Black Diamond, for instance. The town of 2,500 has one dentist. “The best places for these clinics to set up are in the small towns,” says Judson.
Yet Dr. Darryl Smith, president of the CDA, is not convinced that independent practice will solve the access problem. “Dentists have had independent practice. Physicians have had independent practice,” he says. “Dental hygienists gain independent practice: does that mean they’re more likely to establish a practice in a small town that can’t attract a dentist? I don’t know.”
Blame it on the Claim
While the majority of dentists (64%) use CDAnet to send claims electronically to insurers, the CDHA is currently working on a similar electronic claims system (CDHAnet). It is expected to be ready sometime in 2008. And there are any number of opinions from insurers on how much extra work there’ll be, in terms of inputting hygienist codes and fee guides into the system.
Until CDHAnet is ready, both hygienists and insurers will have to contend with paper claims. But it hasn’t been easy. “[For] almost every single client right now who has insurance,” says Margit Juhász, an independent registered dental hygienist practising in Port Credit, Ont., “at one point or another, I’ve already been on the phone with the insurance company.” For instance, one client she saw in December had his claim denied because the insurer wanted the dentist’s unique number (a sort of registration number for usage of insurance claims). “My unique number was on it! I spent 15 minutes on paperwork and phone calls.” Insurers also question the CDHA codes, which hygienists use instead of the CDA codes. “I’ve had to put the CDA codes beside [the hygienist codes]; also a little note attached notifying that these are CDHA codes and they’re comparable to this,” says Arlynn Brodie, a registered independent hygienist in Kelowna, B.C. “But it also would depend on who touched it. Sometimes you get them paid and sometimes you don’t.”
CDHA executive director Susan Ziebarth says she currently fields practical questions from insurers about both unique numbers and codes. Insurers have also asked her to guess how many dental hygienists are going to start billing independently. Although she won’t give an actual number, Ziebarth says that the calls she’s received from independent hygienists has “grown exponentially.” “I used to know pretty much all of them, and now I don’t.”
Others, however, are not convinced there’ll be a significant increase in independent practitioners. Michele Bossi, health and welfare practice leader for Toronto with ACS/Buck Consultants, says she’s not sure how many hygienists will want to take on the stress of a new business. Juhász, too, doesn’t believe that hygienists are ready to take that step. “[From] what I’ve seen and I see, I think the public is much more ready for us than dental hygienists for the public,” she says. In January, the CDHA held a workshop in Toronto on establishing a private dental hygiene practice. Although it sold out, Juhász isn’t fazed. “When we are 10,000 of us in Ontario and only 150 come out to a workshop, that tells me a very small fraction of us are ready.”
Judson, however, is ready. She currently works every Tuesday and two Saturdays a month at Mountain View amid the mild, mild west of her clinic. “I want to make sure that when people come in, they get an unthreatening, very comfortable feeling and when they leave, they leave with a smile on their face.”
Brooke Smith is assistant editor of Benefits Canada. brooke.smith@rci.rogers.com
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