22 September 2023

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Claims analysis of Medicare fee-for-service oral health care encounters

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Background

Many qualifying people rely on Medicare fee-for-service (FFS) for their health care insurance, although it rarely provides coverage for oral health care services. The objective of this study was to gain insights into oral health care that is being provided by all health care provider types for Medicare FFS beneficiaries.

Methods

The authors used the Centers for Medicare & Medicaid Services Virtual Data Research Center to query 100% of Medicare FFS claims from 2019 through 2021. They identified all encounters for which there was either an oral health–related International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code or a CDT 2019-2021: Current Dental Terminology code recorded on the claim.

The authors used a cross-sectional study design and calculated descriptive statistics to describe characteristics of identified oral health care encounters. The encounter level was the unit of analysis.

Results

A total of 2,098,056 oral health care encounters were identified through Medicare FFS claims during the study observation period, with a lower volume observed after 2019. Nearly 98% of encounters were related to those in which oral health diagnoses were recorded (International Classification of Diseases, Tenth Revision, Clinical Modification code on claim), and non–oral health care providers primarily submitted these claims.

Most encounters included beneficiaries with chronic conditions, and a roughly equal proportion included those qualifying for Medicare on the basis of age and disability.

Conclusions

Previously unreported characteristics of oral health care encounters were identified through administrative claims, providing insights into oral health care being provided to a subset of Medicare FFS beneficiaries.

Practical implications

Future research and policies should focus on strengthening medical-dental integration models and expanding access to oral health care for the Medicare FFS population.

Darien J. Weatherspoon, Susan Hutfless and Richard J. Manski. "Claims analysis of Medicare fee-for-service oral health care encounters, from 2019 through 2021." JADA. 12 September 2023. DOI:https://doi.org/10.1016/j.adaj.2023.08.002.