Issues Regarding Insurance and Other Third-party Reimbursement for Behavioral Management Procedures

Issues related to reimbursement for time and effort expended in providing behavior management services for children often result in confusion and frustration for the parent and practitioner. Multiple medical and dental insurance plans within a state or region frequently lack a common set of definitions that are fundamental in interpreting and applying contract language. Ambiguities and inconsistencies in state and federal programs and regulatory structures, as well as budget concerns, only exacerbate the problem. This paper reviews issues of third-party payment associated with dental care for children requiring behavioral management. An environmental assessment of the health care system identifies individual and societal challenges. A model that identifies stakeholders involved in third-party reimbursement is discussed, noting the incentives faced by each stakeholder and expected behaviors based on those incentives. Strategies for effecting change based on a thorough understanding of each stakeholders' concerns are discussed.