The Dental Care Board of Management (NJC Part) is responsible for the overall administration of the Plan, resolving members' complaints regarding eligibility or claims disputes with the Administrator, monitoring the claims settlement performance of the Administrator, and recommending changes to the Plan.
Committee Advisor: Jennifer.Ballantyne@njc-cnm.gc.ca
Quarterly Report to the National Joint Council (June 2019)
Regular activities:
- The Board has met once (1) since the last Council meeting and examined four (4) appeals.
- The Committee welcomed a new Employer Side member, Jane Manuel from TBS.
- The Board reviewed four (4) appeals regarding benefits denied for services. Three (3) were denied in accordance with the limitations of the Plan, one (1) was granted as it was demonstrated that it was not reasonably possible for the member to submit the claim within the 15 month period and the condition for benefit payment within the 24 month requirement had been met.
- The Board received a presentation on Fraud Prevention and Detection from Great West Life (GWL) which included the definition and landscape of fraud, program strategy and current program results.
- Going forward, GWL will provide information related to the following: unusually high amount of scaling (especially for minors), unusual use of exam codes, multiple filings on the same tooth and unreasonable amount of “time in the chair”.
- While the Board expressed appreciation to GWL for addressing inappropriate billings, it has yet to receive information regarding the top dental providers and their gross billings per service category. The board would like to note that this information is essential in ensuring transparency of provider reviews. As such, the board has requested that quarterly reports from GWL include the numbers of providers profiled, audited, referred to licensing authorities and the amount reclaimed from aberrant billings.
- The Board also received financial updates from GWL and can expect a presentation of its Annual Report at a meeting scheduled for June with all other PSDCP Boards of Management.
Outstanding item(s):
- The Board has nine (9) outstanding appeals; of these, five (5) are scheduled to be heard and four (4) are awaiting comments from the Administrator.
Next meeting: October 1, 2019