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ADA, NADP share views on dentists' concerns—Part 1

Dental claims denials were among the most frequent concerns ADA members complained about to the ADA during 2005.

The topic kicks off a series of ADA News articles on dentists' "Top 10" concerns submitted to the ADA about their dental claims. These articles will include perspectives from ADA members, National Association of Dental Plan members and the Council on Dental Benefit Programs on specific issues.

"This series of ADA News articles grew out of CDBP discussions with NADP about our members' most frequent complaints," said Dr. Alan E. Friedel, chair of the council. "CDBP is working with NADP and the payer industry to facilitate communication to eliminate some of the problems our members and patients are experiencing. We want to clarify what information is necessary to adjudicate claims in a timely manner and consistent fashion."

The Council on Dental Benefit Programs maintains a close watch on industry trends, tracks complaints from members and, when appropriate, works with individual companies to seek solutions.

NADP member companies represent some 82 percent of the estimated 163 million Americans covered by dental benefit plans. Dr. Preddis Sullivan, of NADP's Professional Relations Commission, commented that while no one response can fully reflect the breadth of all plan designs and benefit adjudication requirements, the NADP developed a broad overview on claims denials overall.

"Responding to dentists' concerns required complex information collection, as well as broad circulation of the responses to dental plan members," said Evelyn F. Ireland about the topics to be covered in the series. The NADP executive director said, "We did this to assure the NADP perspective reflects, to the extent possible, the diversity of plans and products of its members and the dental benefits industry overall."

This installment features two topics falling under dental claims denials. An upcoming issue of ADA News will feature two more. Subsequent articles will cover the remaining "Top 10" concerns, which include bundling, processing delays, lost attachments, overpayment requests, post utilization review, provider contract issues and more.

Dental Claims Denials
D4341, D4342 coding for periodontal scaling and root planing (SRP), per quadrant or partial quadrant

Dentist perspective

Many dentists don't understand why claims for SRP are denied when the patient has abnormal pocket depths. A claim may be paid on a patient with 4mm pockets while at other times the same payer may deny the same procedure for another patient who had the same or similar clinical presentation.

This is very confusing for dentists. When the claim is denied some patients may think that the dentist is performing unnecessary procedures.

When patients or members of the dental office staff contact a payer to determine whether a benefit is available under a specific plan, they are usually given a yes/no response. Specific payment guidelines may not be provided. If these were provided, the process would be much more transparent and many of these situations could be avoided. Until this is common practice, the carrier should make it clear to both patients and dentists that while SRP may be necessary, their plan will only provide a benefit when the plan's particular clinical indicators are present. If third-party payers disclosed the actual payment parameters, dentists could then tell the patient in advance what the plan might cover.

The ADA Council on Dental Benefit Programs notes that a single payer can reimburse various employee groups differently. In some cases payers act as insurers. In other cases they simply administer a policy on behalf of an employer. Purchasers of plans that cover many lives can often negotiate changes in reimbursement rates to meet economic targets. Dentists should advise their patients that coverage is often based on employer funding of the policy purchased rather than the clinical need of the specific patient.

Dental benefits industry perspective

Payers' standard clinical policies relating to coverage of specific procedures are developed based on a review of the scientific literature, the experience of their dental professionals, dental advisory councils and claims histories. A payer's standard practice in an area such as SRP may be modified for a particular employer based on that employer's preferred or negotiated benefit design, analysis of the employer's claims history, or recommendations of their benefits consultant. Thus, two claims to the same payer with a similar patient profile may be treated differently based on the employers' group dental policy under which each patient is covered.

While a pocket depth of 4mm or greater is the most commonly recognized indicator in the literature for SRP, there are differences within dentistry and dental literature about the specifics of pocket depths as benchmarks. Thus, payers establish their own criteria based on all these factors which can differ from payer to payer and potentially, from one customer to another within a single payer's book of business.

Just as payers' clinical policies differ, claims for periodontal procedures and treatments are frequently subject to coding variations when submitted by dentists. The addition of code D4342 has been helpful in determining appropriate benefit reimbursements. In the past, when code D4341 (full quadrant) was the only SRP code, it was more difficult to determine coverage where diagnostics supported SRP for a small number of teeth in a quadrant.

The use of D4341 or D4342 in reporting more than 2 quadrants within a single dental visit will usually trigger a request for additional information such as a full-mouth periodontal charting, full-mouth X-ray, periodontal diagnosis and the treatment plan.

Many payers now post their guidelines to their Web sites (usually in a member protected area due to the inclusion of CDT codes which are copyright protected), include them in the provider office reference guide or make them available to dentists on request.

Tips for minimizing claim denials or delays for SRP:

  • Before submitting a claim for SRP, check the company's guidelines on their Web site or in the provider office reference guide.
  • When submitting SRP for more than 2 quadrants within a single visit, include documentation—full-mouth periodontal charting, FMX, periodontal diagnosis and the treatment plan.
D4910 coding for periodontal maintenance

Dentist perspective

According to the Code on Dental Procedures and Nomenclature, this procedure is performed following periodontal therapy and continues for the life of the dentition. Periodontal maintenance is often denied, however, because many carriers have limited benefits for this procedure. Reports received from our member dentists indicate that some payers have limited this procedure to being paid as a benefit only within 2 to 12 months of SRP. No mention of a time period following periodontal treatment is provided in the Code. Some payers have qualified periodontal maintenance by denying benefits for this procedure unless two or more quadrants have received prior therapy.

It seems that each carrier has different policies/limitations for this procedure. This is very confusing for both dentists and patients. While the dentist is performing and reporting the correct procedure, benefits are denied solely because of the plan's limitations. However, absent a full explanation that accompanies the denial, the patient may think that the dentist is incorrectly reporting or performing dental procedures. Disclosure of the processing policies in the employee benefit booklet and in an Explanation of Benefits would be very helpful to avoid inadvertent negative implications with respect to the doctor-patient treatment. Allowance of an alternate benefit for a lesser procedure should also be disclosed in the benefit booklet and the EOB.

The ADA Council on Dental Benefits believes it is incumbent upon dentists to deliver appropriate care to patients based upon clinical need, not by third party reimbursement that may be forthcoming. After periodontal therapy has been completed, newly exposed root structure and altered architecture often make debridement of plaque and calculus more difficult. This does not change with time.
Patients should be told in advance that plan provisions may not provide for reimbursement of D4910 for extended periods. We must code for what we do, and educate our patients that all procedures are not covered by all plans.

Dental benefits industry perspective

Quite frankly, this code is a challenge for benefits administrators as well. In order to appropriately determine the benefit for procedure code D4910, it is necessary to have knowledge of the patients' prior periodontal history. Often, this information is not available during claims processing. If the patient has no prior claim history with the payer, or previous periodontal services were not paid by the current payer, it is difficult to properly assess the benefits level available to the patient.

If you are aware that the current payer does not have previous periodontal history on a patient, submitting periodontal charting with the claim will assist in the determination of benefits. Since most payers electronically store claim forms, submitted diagnostics and electronic attachments, an existing record will reside with the payer should there be any question as to the handling of the benefits reimbursement. Thus, resubmission of diagnostic materials would not be necessary on a patient whose periodontal therapy was covered by the payer.

Many payers require an examination, targeted periodontal probing, and a periodontal ­ diagnosis for reimbursement of code D4910. As stated in the Code on Dental Procedures and Nomenclature, this procedure is instituted after periodontal therapy.

Although no time frame is outlined in the CDT, most payers require a waiting period of 8 to 12 weeks. If there are unusual circumstances that would require a different interval of treatment, documentation by the dentist with the original claim submission should forestall requests for additional information to determine the patient's benefits.

At times, payers are limited by specific guidelines from employer group and dental group contract language. When plan limitations exist, and continued D4910 are reported, many payers will allow payment for an adult prophylaxis, which is an integral component of the more global D4910, to provide some level of coverage for the insured patient.

Tips for minimizing claim denials for periodontal maintenance:

  • If there are unusual circumstances that require a different interval of treatment than the one specified in the patient's plan ­ documents, the dentist should provide documentation with the original claim submission.
  • If a patient is covered under a new group policy, submission of the patient's history of treatment with the initial claim for D4910 will assist in the determination of benefits for the patient.