Letters: Redefining codes
April 23, 2012
Kudos to Dr. Andrew Gazerro concerning insurance companies redefining codes ("Letters," March 19 ADA News).
When an insurance company "disallows" a procedure, it negates the reason those procedures were done. If in contract with an insurance company, we cannot balance bill the patient.
Case in point: Delta and codes D3110 and D3120. After multiple conversations, I found that under no circumstance will Delta reimburse for those codes. Although it is a matter of semantics with Delta, it is a denied code. Only if Delta can provide another code to accompany the use of 3110 and 3120 for which reimbursement can be made, does Delta have standing to deny reimbursement.
Few people remember the days without insurance, but when Delta became a player in the insurance field, we were routinely placing Dycal under all composites because we feared adversely affecting the pulp with etched dentin. That is the origin of the basis for Delta disallowing payment for the codes. With the advancement in dentistry, it is time for Delta to also "step up" and advance the reimbursement for valid use of D3110 and D3120. If they need verification for necessity, they can ask for a radiograph like they do for other procedures.
Brian D. Coerver, D.D.S.
Editor’s note:According to the ADA Council on Dental Benefit Programs, a dentist’s clinical decisions determine what services are in the patient’s best interests. The council believes that when a dental plan elects to disallow a procedure, this action does not negate the reason(s) for the service provided. Rather, a determination to disallow is an illustration of how a dental benefit plan’s limitations and exclusions may not provide reimbursement for necessary dental procedures.