e-mail Print Share

Letters: Disallowed claims

September 19, 2016 Interestingly, this current discussion on disallowed claims (“Association Asks Delta Dental to Reject Proposed Disallow Policy,” May 16 ADA News) started with me and my practice partner Dr. David Moore, who is an ADA delegate. We brought a resolution to the 14th district and to the ADA House of Delegates. Who says individual dentists can’t make a difference?

What some dentists miss is that a disallowed claim is not just denied for payment, but that the dentist performing the work, by contract, cannot collect any payment for the service from the patient. The insurance companies say this is to protect their subscribers from being taken advantage of by unscrupulous dentists or to protect those subscribers from below-standard dental care. My argument is that if there is unethical or substandard care being delivered, it should be reported to the state dental board, whose job it is to look into these matters, not a reviewing dentist making a decision off of one radiograph with no clinical exam. Indeed, the one practicing below the standard of care is the dentist diagnosing the disallowed claim as unnecessary or substandard with no clinical information. Any dentist in a practice would end up in front of their board for such care.

For my part, when I get disallowed claims, I am filing a complaint with the state board against both the dental insurance company and the reviewer. In New Mexico, claims must be reviewed by a dentist holding a New Mexico license. I think, when these companies have to back up their decisions in front of a board, they will realize they should not be interfering in the doctor/patient relationship.

Robert J. Gherardi, D.M.D.
Albuquerque, New Mexico