Study of Alternative Methods of Managing Dental Contract Health Services

There are differences in the scope of dental fudiciary services provided by Blue Cross/Blue Shield (BC/BS) carriers, the for-profit dental insurance companies, and Delta Dental Plans. The objectives of this study are: 1) to evaluate a sample of dental third party administrators (TPAs) capable of managing a national contract for management of Indian Health Service (IHS) dental Contract Health Services (CHS); 2) to evaluate options for IHS Areas and service facilities to manage the dental CHS program; 3) to document requirements of P.L. 93-638 tribes and tribal organizations with regard to management of dental CHS programs; 4) to develop a scope of work (SOW) for a national TPA contract to manage reimbursement for IHS dental CHS resources; 5) to develop a model SOW for FI contracts to manage reimbursement for tribally-managed Dental CHS services; and 6) to develop a model Provider Agreement to facilitate contracting for dental services and assure the delivery of quality services and standards. This project was a case study with interviews of key informants in a variety of organizations including: 1) TPAs; 2) IHS Area Offices and Service Units; and 3) tribes operating dental programs under P.L. 93-638 contracts with IHS. Site visits were made to BC/BS organizations in New Mexico and Michigan; Delta Dental Plans in California, Michigan, and Oklahoma; IHS Area offices and IHS and tribally-managed facilities in Albuquerque, Bemidji, California, Navajo, Oklahoma, and Portland Areas.The results indicated that the TPAs are generally strong in the areas studied: 1) administration and management; 2) claims processing; and 3) quality assurance. The TPAs often provide services that cannot be duplicated by IHS. It seems likely many TPAs would respond to an RFP to provide management and FI services for the IHS dental program. Quality assurance and data systems supporting dental CHR are uneven across IHS Areas. The study revealed four major problem area with Tribal Dental CHS: 1) inadequate information and reporting systems; 2) inadequate documentation of program procedures and associated dependence on individual program managers; 3) inadequate support for contracting and negotiating costs with local providers; and 4) a potential for fraud and abuse.Recommendations are provided in the areas of: 1) national fiscal intermediary contract; 2) valid uses of dental CHS resources; 3) dental CHS budget; 4) provider agreements; 5) quality assurance and appropriateness of care; and 6) tribal participation in fiscal intermediary contract