DrBicuspid.com has teamed with a former dental insurance executive to provide expertise to you and your staff for maximizing your patient's benefits. Twice a month, Doyle Williams, DDS, will give nuggets of advice to help your claims get approved the first time.
A distortion of the Golden Rule used by insurance companies is "He who has the gold, makes the rules." Because most dentists practice in small groups, they may not be able to hire a professional insurance claims processor in their office.
Denial of a crown with an alternate benefit of a filling is always frustrating
Doyle Williams, DDS.Generally, insurance companies allow crowns only when a cusp is missing or decay involves more than three surfaces. It can be difficult to tell on an x-ray if the decay extends to a fourth surface, and, sometimes, if the broken cusp is lingual, an existing filling hides that in the x-ray.
Document your records at the time of treatment, and if an x-ray does not clearly show the need for a crown, then add a narrative to the claim. Photos are usually helpful to show the need for a crown after all decay has been removed.
Down coding a surgical extraction to a regular extraction is common
How can anyone tell from an x-ray whether a tooth needs to be surgically removed? The fact is they can't. Not you or any dental consultant. So let's describe what constitutes a surgical extraction.
According to the definition in the Code on Dental Procedures and Nomenclature (CDT), it requires removal of bone and/or sectioning of the tooth always. It may or may not (but usually does) include a mucoperiosteal flap. The most common reason for denial of the surgical extraction is because only a flap was used. That may have been how it worked in dental school, but not in real life. The dental record is the most important aspect of documenting a surgical extraction, but photos can help here also. You should also be aware that the code includes the alveoloplasty (minor smoothing of the socket and closure).
Denial of a filling because it was done less than two years ago
State dental boards prohibit a dentist from "guaranteeing" their work, yet when you sign a participating agreement with an insurer, many times they hold you to time periods by requiring you to "write-off" all or part of the procedure you have redone.
This tactic is based on good intentions of an insurance carrier trying to protect the member (your patient) from "harm" by a dentist performing shoddy work. If a surface is duplicated in a restoration within 24 months, most insurance carriers automatically deny the new procedure in whole or in part. Because it is done without a human reviewing the code, a narrative usually is not seen.
For these denials, you need to write an appeal explaining why the filling failed. Possible reasons are recurrent decay, new decay adjacent to the filling, fracture of the filling or tooth, and poor oral hygiene by the patient. This should prevent you from writing off the cost, although it could shift the cost to the patient.
Doyle Williams, DDS, spent 24 years as an insurance executive.
The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.
