“In our office, we provide services that we feel are necessary for our patients’ complete dental health. When the insurance company does not cover the services, patients think that I have not billed correctly or that we are doing something “illegal”. I have been asked by the patient to “word it a certain way or to change the code to get it covered.” What can I do to stop this from happening?
Theresa, Insurance Coordinator
This scenario can put you and the dental team in an awkward position. Suddenly you are defending treatment that was diagnosed by the doctor as necessary for the health of the patient. When dental insurance plans deny payment, patients sometimes think we did something to them instead of for them. We are seeing more dental services excluded from plans in order to keep premiums competitive. You can expect to answer more of these questions from patients who are disappointed with the lack of coverage. My recommendation is for you to get pro-active in educating your patients about insurance just as you educate them about periodontal disease. Medical insurance is designed to pay out large sums to cover illnesses until the patient is well. Dental insurance has a per calendar year cap that has not been changed for some twenty plus years thus allowing limited benefits to help a patient with initial steps to get healthy. Never claim to be an “expert” on dental insurance plans because you will be held accountable if the coverage is denied. Instead, ask the patient to bring the coverage booklet in to the office so that you can “discover” the limitations at the same time. If they do not have a booklet then have them witness a call to the insurance company and let them hear the information that you are gathering.
One of the most common areas of insurance frustration is the prophy or “cleaning” versus periodontal disease. Insurance companies emphasize the benefit of two cleanings a year or one in a six-month period. The patient believes that this is all that they need because any more are paid “out of pocket”. Because of this many dental practices do not have active “interceptive periodontal programs” for fear of losing the patient. These offices let the insurance companies dictate treatment to the detriment of the patient’s dental health. Certainly we cannot ignore a bacterial infection because of insurance limitations.
In regards to changing a code so that the insurance will pay, The Health Care False Claims Act states “No person shall knowingly make a false statement or false representation of a material fact to a health care payer for use in determining rights to a health care payment.” Dentists and dental hygienists are bound by legal responsibilities to choose a dental code that most accurately reflects the treatment rendered. If this code is not a covered benefit of the policy you may ask for an “alternate benefit” from the insurance company. If none exists, then the patient is responsible for payment. Dental insurance representatives that inform patients of their coverage over the phone are not aware of the penalties that dentists and hygienists can suffer by manipulating treatment codes in order to obtain benefits. Tell the patient to speak to their employer about increasing benefits or adding coverage for periodontal disease and maintenance to the policy.
Learn more about navigating the insurance maze by enrolling in our Advanced Business Training through The Center for Dental Career Development.
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