Digital Radiography and California Third Parties

Acceptance of digital radiography is increasing but has not yet progressed to the mainstream. A key factor in widespread use of this advancement is acceptance -- both theoretical and technological -- by dental health plans for claim submissions. This article details a survey of California third parties to examine their practices, concerns, and plans regarding digital dental radiography.

Interest and acceptance of digital radiography in dentistry is undeniably on the increase. A previous issue of the Journal of the California Dental Association, wholly devoted to oral radiology (May 1995), featured traditional topics of quality assurance,¹ infection control practices,² oral pathology case diagnosis,^3,4 radiation risks and safety,⁵ and "The Don’ts of Maxillofacial Radiology."⁶ The only mention of digital maxillofacial radiography was found in Langlais and Langland’s⁵ article on radiation safety. They primarily described the reduced dose advantages of these systems but also presented general technological features and listed other advantages of digital radiography, which -- at that time -- was still in a period of relative infancy.

In October 1997, the Journal highlighted "Technology in Dentistry" and featured an article by Denton and Thomas⁷ titled "Digital Radiographs -- Will the Future Ever Arrive?" Now, this issue of the Journal is entirely devoted to the topic of digital maxillofacial radiography. Martin⁸ estimates that 5 percent of dental offices faithfully incorporate some form of digital radiography into their practices.

A variety of factors are promoted and recognized as advantages of digital imaging over film-based imaging and thus are forces behind the trend. Reduced patient radiation dose; elimination of darkrooms, with their messy chemistry and hazardous waste disposal concerns; increased efficiency resulting from no delay in the production of a viewable radiographic image; promotion of the "cutting edge" image of the practice; and cost-effectiveness are some of the commonly discussed advantages of digital imaging systems. In addition, communications and interactions with third-party insurance carriers are improved by the capability of transferring digital radiographic information electronically. Farman⁹ reported that "approximately 20 percent of dental services covered by third-party insurance carriers in the United States require submission of radiographs for prior approval of treatment" and that electronic submission of radiographs in digital format for preauthorization of treatment and for proof of services rendered reduces administrative costs, shortens delays in treatment and reimbursement, and eliminates the potential loss of original film-based radiographs if mailed. Martin⁸ also outlined advantages of digital radiographic images related to third parties. He described digital radiographs, either printed on paper and mailed or submitted electronically, as being a fraction of the cost involved of processed film. He added, "Insiders … are hopeful that as more images are submitted electronically, third-party payers will be more likely to divvy out higher reimbursements at a more expedient pace." Davis⁹ believes that the advantage of electronic transfer of radiographs to insurance carriers is yet to be proven. He states: "In reality, very few, if any, insurance companies are either equipped or actively encouraging practitioners to submit (digital dental radiographs) electronically." Denton and Thomas⁷ outlined several benefits of using digital radiographs in a modern dental practice but also included an analysis of insurance companies and the obstacles they face in becoming equipped to manage electronic data interchange (EDI). They believe that, "Overall, dental insurance companies have been slow to modernize their backroom operations, including EDI, in comparison to trends in many other industries."

The authors of the current article investigated the practice, attitudes, and plans of third parties with respect to digital radiography and its promises. Specifically, the purpose was to develop and distribute a survey to the 34 dental health plans registered in the state of California to determine their policies, practices, plans, and concerns related to the use of digital dental radiographs in the processing of dental insurance claims. This information may assist dentists who are seeking to understand the value of digital radiography systems as they incorporate them into their practices.

Materials and Methods

A list of 34 dental health plans, licensed by the California Department of Corporations, was obtained from the coordinator of CDA’s Council on Dental Care. For each company listed, a contact person was identified. A simple survey form was developed requiring no more than 10 to 15 minutes to complete. This survey was mailed in December 1998 to each company’s representative officer. If no response was received after three weeks, a telephone call or second mailing was made in an attempt to include the greatest number of health plan companies in the study.

Three categories of questions were included in the survey. The first category focused on the company’s size and reliance on electronic claims processing in general. The second related to the acceptance of digital dental radiographs either in printed or electronic form and what software systems were being used to process the images. The survey also inquired about the timetable for implementation of such a system if one did not currently exist. The third category related to the company’s comfort level with the integrity and quality of the information contained in radiographs in a digital format. In this category, one question was designed to determine preferences for groups who should set industry standards.

Results and Discussion

An overall response rate of 24 percent was obtained. This was much less than anticipated, and therefore the findings presented do not represent a majority of California third parties. However, certain themes emerged that are worthy of reporting and that merit watching as the digital radiographic trend continues. A summary of the following results may be found in Table 1.

The dental health plan companies that did respond reported a range of 4,000 to 600,000 claims processed monthly. Therefore, the data that could be collected includes companies that are relatively small and the very largest. For all claims processed, approximately one-third are received by the responding companies in electronic form. Half of the companies reported using a "clearinghouse" to facilitate the processing of claims. One of the dental health plans responding indicated that it operates a prepayment or capitation-type plan and therefore does not process claims of any kind. This underscores the fact that these types of plans are not reliant on interchange of administrative or radiographic records related to treatment and thus are not planning for the implementation of systems designed to expedite this process electronically.

None of the responding dental health plan companies currently accept electronic transfer of digital radiographic images; however, 50 percent of the responding group indicated that they do accept printed copies of digital radiographs for processing dental claims. This seems to indicate an implicit acceptance of the use of this technology. Two companies reported that pilot programs to implement electronic reception and processing of claims containing digital radiographs would begin as early as 1999, continuing into the year 2000. These companies also reported that the number of dental offices using digital imaging is a major influence on this initiative. One source, close to the industry, identified the slow transmission times involved when sending and receiving the large volume of data contained in an electronic file of a dental radiograph as one of the major obstacles encountered in early trials involving electronic transfer. The typical graphic image of a digital radiograph requires from 250 to 2,500 kilobytes of storage memory, depending on the resolution of the sensor used to acquire the image. To transfer the largest of these images over a 56 kilobit/second modem in an uncompressed format would take nearly six minutes, assuming that the modem connection allowed maximum transfer speed. Various compression techniques reduce the size of these image files, making electronic transfers more manageable but at a loss of image content. One of the questions needing to be answered by third-party payers is how much image compression they will accept for the sake of efficiency in electronic transfer and still maintain their confidence in the diagnostic content of the image. To be efficient, the insurance company must be able to receive the radiographic information in a manner that is timely with respect to their computer systems responsible for handling the task. This problem may be alleviated in the future as broadband technologies become more widely available.

Because electronic transfer of digital dental radiographs is in the early stages of implementation, several of the survey questions were premature and could not be answered by the companies queried. However, these questions are valid for dentists who eagerly await the day when they can file a dental claim with the click of a mouse, complete with radiographic documentation, as well as for third-party payers planning to receive and process those claims. These questions include:

* Does your company differentiate between radiographic images that have been scanned from original films and those that are digitally acquired?

* Which of the following formats (JPEG, GIF, TIFF, PICT, other) for graphic image transmission does your company accept when digital dental radiographs are submitted electronically?

* What software does your company use for viewing image files containing digital radiographs?

* Does your company’s claims processing personnel routinely use image enhancement features to obtain diagnostic information related to the claim when reviewing electronically submitted dental radiographs?

* Does your company have a support system, such as a contact person or hotline for dental offices to use, if problems are encountered with electronic transmission of claims or radiographic images?

* What is the difference in turn-around times for settlement of claims by your company for the following categories: paper claims with original film-based radiographs, electronic claims with hard-copy digital radiographs, and electronic claims with electronically submitted radiographs?

A seventh question, although not in the survey, should also be considered: Does your company’s software system support Supplement 32 of the DICOM Standard? DICOM is an acronym for digital imaging and communications in medicine, with Supplement 32 having been recently written to cover all imaging modalities used in dentistry. Adherence to the standard permits devices manufactured by a variety of vendors to "talk to each another" more readily and therefore ensure interconnectivity. For example, until some standard prevails, there can be no guarantee that a digital X-ray system will be able to communicate with a particular dental office management software, intraoral camera system software, or dental health plan’s software. Digital X-ray imaging companies are in the process of conforming to the new standard or have indicated their intended support. As third parties prepare to meet the challenge of increased electronic exchange of radiographs, they should plan to implement systems with DICOM Standard compatibility.

The survey also prematurely questioned the companies’ experience with image quality, asking them to compare the image density, resolution, contrast, and diagnostic accuracy of digital radiographic images and original, film-based, radiographs. It also asked for a comparison of the same variables between digital radiographic images and film-based duplicates of original radiographs. A single company indicated that hard-copy digital radiographs were somewhat better in quality than original film radiographs. Other companies did not respond to this question. Third parties will need to develop confidence in the quality of electronic images as compared to traditional film-based images currently in use, and the parameters that control diagnostic image quality will need to be similar to that of film.

With respect to dental health plan companies’ comfort level with the integrity of information contained in digital radiographs, all responding companies rated this issue as either a moderate or major concern. There was 100 percent agreement that unmodified digital files of radiographs need to be ensured by one method or another. Here again, a standard for ensuring image integrity would assist in the progress toward implementation of electronic transfer of radiographs for insurance communications. In spite of the companies’ stated concern for image integrity, it could not be determined how companies who accept hard copies of digital radiographs were able to ensure the integrity of those images. When asked about dental health plan companies’ preferences regarding which entity should develop industry standards for ensuring the integrity of electronically submitted dental radiographs, companies favored their own dental health plan industry (25 percent) or a consortium of groups (37 percent) over the digital radiographic equipment industry (0 percent).

Conclusions

Realistically, there are greater benefits to owning digital dental radiographic systems than their ability to facilitate better claims processing by electronic submission of digital radiographs. Immediate benefits include potential for reduced radiation dose to the patient, increased efficiency resulting from no delay in producing a viewable radiographic image, and promotion of the "cutting edge" image of the practice. Elimination of darkrooms with messy chemistry and hazardous waste disposal concerns will require more effort to effect, for example, when panoramic, occlusal, or other miscellaneous films still need to be processed.

Because the dental health plan industry is in the very early stages of implementing systems that will accept electronic submission of digital radiographs, this benefit will take longer to fully realize. Nevertheless, it appears that the trend is in this direction with the ultimate possible results proving to be quite exciting. With certain companies already pioneering pilot programs for processing claims accompanied by radiographs in digital form, the wait to begin may not be much longer than the time it takes for this article to appear in print. Full conversion to electronic exchange of radiographs is expected to take years to complete. For practices that have yet to acquire digital radiographic software and equipment, careful inquiry should be made regarding the manufacturer’s policy with regard to software upgrades that may be required to enable proper communication with third parties. As support for the DICOM Standard is incorporated into newer generations of software, the older versions will become obsolete.

Authors

Dennis E. Clark, DDS, MS, is a professor and section chief of oral and maxillofacial radiology at Loma Linda University School of Dentistry.

Jon Roxas, BS, is a dental student at LLU School of Dentistry.

Elena Sanz, BA, is a dental student at LLU School of Dentistry.

Mark Menes, BS, is a dental student at LLU School of Dentistry.

References

1. Hadley JN, Dental radiology quality of care: The dentist makes the difference. J Cal Dent Assoc 23(5): 17-20,1995.

2. Puttaiah R, Langlais RP, et al, Infection control in dental radiology. J Cal Dent Assoc 23(5):21-8,1995.

3. Schiff T, Hadley JN, et al, Bilateral radiolucency and radiopacity of the mandible. J Cal Dent Assoc 23(5): 29-30,1995.

4. Abramovitch K, Radiopacity in the posterior mandible. J Cal Dent Assoc 23(5):31-2,1995.

5. Langlais RP, Langland OE, Risks from dental radiation in 1995. J Cal Dent Assoc 23:33-9,1995.

6. Schiff T, Hadley JN, The don’ts of maxillofacial radiology. J Cal Dent Assoc 23:40-1,1995.

7. Denton RV, Thomas J, Digital radiographs: Will the future ever arrive? J Cal Dent Assoc 25:723-8,1997.

8. Martin EJ, Image of the future, move over X-rays -- here comes digital radiography. AGD Impact 26:8-16,1998.

9. Farman AG, Farag AA, Teleradiology for dentistry. Dent Clin N Am 37:669-81,1993.

10. Davis ER, Is dentistry through with film? NY State Dent J 61:34-44,1995.

11. Farman AG, Farag AA, et al, Expediting prior approval and containing third-party costs for dental care. Ann NY Acad Sci 670:269-76,1992.

12. Benn DK, Bidgood WD, et al, An imaging standard for dentistry. Oral Surg Oral Med Oral Pathol 76:262-5,1993.

To request a printed copy of this article, please contact/ Dennis E. Clark, DDS, MS, Room 4405, Prince Hall, LLU School of Dentistry, Loma Linda, CA 92350.

Table 1. Summary of California Third Party Responses to Questions About Digital Dental Radiographs