9.17.10 Issue #445 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter
 


Belle DuCharme CDPMA
Instructor/Consultant
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Set a Standard for Treatment Planning and
Insurance Narratives

By Belle DuCharme, CDPMA

Who does insurance narratives in your practice? Most often, the business coordinator or the insurance coordinator are responsible for extrapolating the information and condensing it to meet each insurance company’s claim submittal requirements. Often when filing the claim, the information has not been provided and questions have to be asked of the doctor or dental assistant who are busy with other patients. When the clinical team is formulating the treatment plan, their main focus is on what the patient needs to get to a healthy state for periodontal and restorative concerns, and to also address some cosmetic recommendations. Not a lot of importance is placed on the existing restoration because it is being replaced with something better. Throw in possible bite therapy and orthodontics, and the treatment plan takes on a life of its own.

Their focus should not be on what the insurance will approve to pay, but rather on what the patient needs and or wants from their dental treatment. No matter what your stand is on insurance, you will need to comply with their requirement of complete information to get the benefit dollars allotted for the patient. Even if you choose not to participate in the world of the PPO, your patient wants reimbursement.  It would be great if all patients would have optimum dentistry, but the truth is that many people put a higher value on the care that is covered by their policy versus that which is not. To get paid, proving that the existing condition is no longer or was never satisfactory lies on the evidence you can provide on an insurance claim.

Take for example the following illustration. A business coordinator was trying to clean up some unpaid claims. On this particular claim, which was now almost six months old, a crown was denied because it was placed on a third molar. A periapical x-ray was submitted, along with a narrative explaining that the crown was an initial placement and the existing restoration was a large MODL amalgam with a fractured mesial cusp undermined by decay. Since most third molars are out of occlusion, there was a claim denial. However, in this patient’s case all of her third molars were present and in occlusion. In other words, failing to restore this tooth would have jeopardized the integrity of her arch. The claim was resubmitted - with 4 bitewings and a periapical of the tooth in question, and one of the opposing teeth with a supporting narrative, and the claim was subsequently paid. 

If your focus is trying to treat what you have found with $1,000 or $1,500 per calendar year, then you are dooming the patient to patchwork dentistry that has a never ending story of trying to solve one crisis after another. Putting together a total treatment plan does not happen on the patient’s first visit unless you can read the future. You will not be able to determine the outcome of your cosmetic recommendations unless the periodontal, orthodontic, endodontic, surgical and bite issues have a favorable outcome. This could take a commitment of a few months to a few years in your practice. Phase the treatment based on your estimation of patient compliance and treatment success one step at a time. Explain to the patient that a clearer picture of their treatment will evolve as each phase is completed satisfactorily. The condition developed over time and now needs to be addressed over time also.

To assist the business staff in this treatment process, use a form that contains the following information not only for proper insurance documentation but for proper record taking. Having more than enough information is better than not enough.  Put this information in the chart notes area in the computer or simply scan into documents.

Diagnostic evidence for tooth #________________
Available PA______FMX___Panorex __ BWX ____Intra-oral photo_________Dated_______
Existing restoration description___________________Estimated age of existing_________Initial placement_______________
Caries evident Active___Incipient____Recurrent decay_____
Fracture__ Chip___Cusp undermined and or weakened____Horizontal or vertical cracks not visible on x-ray____Open margin or defective margin___Overhang or food trap with gingival irritation____Third molar in occlusion________
Porcelain fracture_______Thermal sensitive____Pressure sensitive___Percussion sensitive____Cracked tooth syndrome_____Previous endodontic treatment__________Date____
Pulpal exposure____Failing endodontic therapy____Endodontic referral_______
Missing tooth since______ Implant present____ Date placed____­­­Bruxism evident______
Bruxism contributing to bone recession_________
Occlusion with opposing____Bone recession____

Narratives should be short, while still containing the information that the insurance company asks for to determine payment of a claim. For more help with insurance and all the other issues that affect your day, call McKenzie Management today and sign up for one of our training courses designed to address the real world of the dental practice.

If you would like more information on McKenzie Management’sTraining Programs  to improve the performance of your team, email training@mckenziemgmt.com

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