Predetermination as a Cost-containment Mechanism in a Social Allowances Dental Program in Manitoba

Objectives: A review of dental consultant actions during predetermination of benefits in the publicly insured indemnity program in Manitoba under which Social Allowances Health Services certificate holders receive dental care was under‐taken to determine the value of this process as a cost‐containment mechanism. Methods: Dollar amounts of services denied by a dental consultant during eight predetermination sessions selected to represent the 96 sessions during the 1990–91 fiscal year were determined and grouped according to category of service. Results: Approximately one‐third of average total expenditures each month were reviewed by the dental consultant through the predetermination process. Of the requested dollar amount reviewed, 26 percent was denied, a savings of 8.5 percent of average total monthly expenditures. The categories of services that made up the denied requests were: prosthodontics (30%); endodontics (32%); restorative (5%); periodontics (12%); and miscellaneous (21%), including diagnostic, surgical, preventive, orthodontic, and adjunctive. Conclusions: A properly administered predetermination process can save a third party 8.5 percent of total plan expenditures; dollar changes to altered treatment plans amount to a 26 percent reduction of expenditures relating to these requests. A predetermination process with an unbiased appeal mechanism provides a system to advise and protect providers regarding what treatment is covered.