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ADA, NADP share views on dentists' concerns—Part 2

This is the second installment of a series of ADA News articles on dentists' "Top 10" concerns submitted to the ADA about their dental claims. These articles include perspectives from ADA members, National Association of Dental Plan members and the Council on Dental Benefit Programs.

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

Two more topics under dental claims denials were featured in the Nov. 20, 2006 ADA News. Subsequent articles will cover the remaining nine of the "Top 10" concerns, which include claims processing delays, lost attachments, provider contract issues and others.

Dental Claims Denials
D2950 core buildup, including any pins

Dentist perspective

Many complaints concerning the denial of core buildups were brought to the attention of the ADA Council on Dental Benefit Programs. Dentists perform this procedure when it is necessary prior to restoring a tooth with a crown. Complaints centered on the lack of a benefit for this procedure. Some dentists complained that this procedure is bundled with a crown procedure.

Bundling of separate procedures to limit a benefit is against ADA policy. If a plan chooses to bundle these procedures, the plan should allow the sum of the fees for the crown and the crown buildup as the total fee for the procedure and provide the appropriate benefit. Dentists do not always understand the parameters for payment by plan. Patients should be clearly informed as to benefit limitations and it should be made clear in the benefit booklet and explanation of benefits that plan limitations and not clinical necessity determine payments.

CDBP notes that many patients do not understand how their dental benefits really function. They do not understand that dentists who attempt to deliver ideal care may find that the constraints of a given policy do not align with the treatment plan. It is incumbent on us to give appropriate care notwithstanding a patient's insurance coverage. This is an example of just such a situation. We cannot interpret the meaning of any code beyond what it actually states.

The payers who choose not to fund for core buildups do so for many reasons. Having patients who understand the limitations of their plan prior to treatment can avoid problems.

Regarding explanation of benefit language, CDBP works very hard to help insurance companies find language which is not only succinct but which does not infer bad faith on the part of the dentist. We have had some success in this regard by direct correspondence with individual companies.

It is incumbent upon the dentist to help the patient understand the clinical basis for treatment, in spite of contractual limitations by the plan. In doing so, the rationale for the core buildup to improve retention form and improve the clinical outcome is clearly explained for the benefit of the patient. In cases of denial, it may be appropriate to submit an appeal outlining the reasons for the procedure, leading to improved prognosis.

Dental benefits industry perspective

Both this code and D6973 core buildup for retainer, including any pins, creates problems for payers. Some of the problems result from limitations in an employer's group policy and some result from lack of documentation to support use of this procedure in addition to a crown.

The change in the descriptor in CDT-4 clarified the procedure, however all claims submissions are not consistent with the descriptor. In the description it states the procedure, "Refers to building up of anatomical crown when restorative crown will be placed, whether or not pins are used. A material is placed in the tooth preparation for a crown when there is insufficient tooth strength and retention for the crown procedure. This should not be reported when the procedure only involves a filler to eliminate any undercut, box form or concave irregularity in the preparation."

Some payers find that buildups are reported in addition to a crown procedure when there is a base placed only to restore undercuts and tooth structure that is removed during the crown preparation. This is contrary to the descriptor for this code. Under this definition, a dental consultant acting on behalf of the payer may decide, based on the documentation submitted, that the reported crown buildup did not meet the definition and is a part of the crown procedure. Thus, only the crown procedure will be reimbursed.

Benefit limitations are required, under state law or in the case of Taft-Hartley contracts under negotiated labor agreements, to be disclosed in plan documents that are provided to insured patients. These documents must meet readability standards which are most often at the grade school reading level and sometimes are required in foreign languages as well. While these plan documents are made available to insured patients, they may be lost or misplaced and thus not referenced by the patient when seeking treatment.

EOB* language is intended to be succinct yet descriptive of the payers' action relating to the patient's claim. Payers are often limited in the space provided for explanations and use shortened descriptions to convey information. When such language results in misunderstandings between the patient and the dentist, payers are open to suggestions for changes in language.

Tip to minimize claim denials for core buildup:

In the initial claim submission, documentation of the condition that resulted in the buildup should be provided, if applicable.

*The National Association of Dental Plans has recently distributed to its members the ADA Council on Dental Benefit Programs' summary, "ADA Position on Content of Explanation of Benefits (EOB) Statements."

Pre-authorizations

Dentist perspective

Although it is incumbent upon patients to understand their coverage, many times the policies are not easily understood by lay people. It can be time consuming for the dental office to first learn about and then explain the terms of any particular policy to a patient. Also, since policies can change at the beginning of a plan year, this can make it very difficult for any dentist to understand how they will be paid for any procedure. Dentists use the pre-authorization process to determine a patient's coverage.

Sometimes a treatment plan has been pre-authorized or pre-approved by the carrier and the treatment is performed by the dentist with the expectation that the claim will be paid, but it is denied. The reasons for denial vary, such as the patient is no longer eligible, the maximum allowable has been paid or time limitations have been exceeded. The pre-authorization should clearly indicate that the pre-authorization is not a guarantee of payment.

The ADA Council on Dental Benefit Programs believes that if at all possible, patients should be empowered to get paper or internet copies of benefit booklets and policy guidelines so they can make informed decisions.

When a preauthorization is received in one calendar year and is begun in the next, there is always the potential for a problem.

The slow turnaround on a preauthorization often creates frustration for patient and practitioner. The process can be used to uncover proposed treatment which is not covered or is disallowed.
Patients must understand the benefit outlined in the preauthorization is tempered by the allowable benefits at the time of service, not the time of preauthorization submission.

Dental benefits industry perspective

The complexity of dental benefits is market driven. However, employee benefits booklets and disclosure statements are required by state laws to be written at a grade school reading level and in some instances provided in languages other than English to facilitate patient understanding.

The involvement of the dentist in explaining benefits to patients varies by dental product.

In dental health maintenance organizations, network dentists are provided with a manual or Web site access that lists covered benefits and patient payment obligations. Since there is no routine claims process for DHMOs, there is an expectation that the dental office is explaining charges for covered services (co-payments) and non-covered services when they are completing treatment.

For dental preferred provider organizations (roughly half of the market today) and dental indemnity plans (about 26 percent of the market), payers do not expect dentists or their office staff to explain covered benefits to the patient. While dentists may elect to provide general information about benefits based on their experience, payers make specific information available to patients through their Web sites, benefit booklets and customer service lines.

"Preauthorization" and "predetermination" are processes that payers make available to dentists to clearly determine the potential benefits for a specific patient. These are distinct and different terms and processes which are outlined in many state statutes. They are not interchangeable. ("Pre-approved" is not a term generally used by payers.)

Many DHMO plans require preauthorization prior to referral to a specialist so that the plan can review the treatment prescribed and authorize payment. However, even with a DHMO, eligibility must still be established at time of service for a benefit to be covered.

Most DPPO and dental indemnity plans do not require preauthorization but offer a voluntary predetermination of ­ benefits process. This is a service to the dentist or patient to determine prior to treatment what their plan will cover and reimburse for the course of treatment presented if the patient does two things:

  1. remains eligible;
  2. has not exhausted the plan maximum at the time of service.

Most carriers do clearly note on these forms of advice about potential coverage that the estimated payments for services are not guaranteed. Whether it is a preauthorization or a predetermination (sometimes called pre-estimate), it is based on the eligibility and remaining benefits at the time it was issued. If a member loses coverage or other benefits are paid in the time between the preauthorization or predetermination and the submission of a claim, benefits would change.

Dental insurance is like other types of insurance, the actual coverage is determined on the date of occurrence. If any eligibility of coverage has changed, the benefits are adjusted accordingly.

Tips to minimize claim denials and promote patient understanding of benefits:

  • Encourage patients to contact their payer directly through customer service lines to verify benefits for particular procedures.
  • Submit predeterminations on complex, costly procedures as close to the date of proposed service as possible.