Miranda Geraldo Elias, Siqueira Marta Cristina Portes, Ferreira Ricardo Luiz Siqueira Magalhães, Delwing Fábio, Daruge Júnior Eduardo
Department of Social Dentistry, Piracicaba Dental School, University of Campinas, Piracicaba, SP, Brazil.
Braz Oral Res. 2015;29. doi: 10.1590/1807-3107BOR-2015.vol29.0041. Epub 2015 Feb 16.
The objective of this study was to assess the prevalence and the type of claim denials (administrative, clinical or both) made by a large dental insurance plan. This was a cross-sectional, observational study, which retrospectively collected data from the claims and denial reports of a dental insurance company. The sample consisted of the payment claims submitted by network dentists, based on their procedure reports, reviewed in the third trimester of 2012. The denials were classified and grouped into 'administrative', 'clinical' or 'both'. The data were tabulated and submitted to uni- and bivariate analyses. The confidence intervals were 95% and the level of significance was set at 5%. The overall frequency of denials was 8.2% of the total number of procedures performed. The frequency of administrative denials was 72.88%, whereas that of technical denials was 25.95% and that of both, 1.17% (p < 0.05). It was concluded that the overall prevalence of denials in the studied sample was low. Administrative denials were the most prevalent. This type of denial could be reduced if all dental insurance providers had unified clinical and administrative protocols, and if dentists submitted all of the required documentation in accordance with these protocols.
本研究的目的是评估一家大型牙科保险计划的索赔拒付发生率及类型（行政性、临床性或两者皆有）。这是一项横断面观察性研究，回顾性收集了一家牙科保险公司的索赔和拒付报告数据。样本包括网络牙医根据其2012年第三季度的诊疗报告提交的付费索赔。拒付被分类并归为“行政性”、“临床性”或“两者皆有”。数据制成表格并进行单变量和双变量分析。置信区间为95%，显著性水平设定为5%。拒付的总体发生率为所执行程序总数的8.2%。行政性拒付的发生率为72.88%，技术性拒付为25.95%，两者皆有的为1.17%（p<0.05）。研究得出结论，所研究样本中拒付的总体发生率较低。行政性拒付最为普遍。如果所有牙科保险提供商都有统一的临床和行政协议，并且牙医按照这些协议提交所有所需文件，这种拒付类型是可以减少的。
