11.20.15 Issue #715 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Belle DuCharme, CDPMA
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Dental Plan Contracts and Processing Policies: Required Reading
By Belle DuCharme, CDPMA

Dear Belle,
I just read an EOB that is denying payment on a claim for a crown based on a policy frequency of 84 consecutive months per crown per tooth. I thought it was 60 months or 5 years replacement. The crown needed to be replaced. When we obtained benefits, crowns are covered at 50%? There should be a warning to read the fine print.  
Stewing Doc in CA

Yes, having dental benefits for a procedure doesn’t mean there will be payment for the procedure. The list for benefit limitations can be as long as the list for covered benefits. Also make sure to read the benefit exclusions of the plan to further understand the policy procedures. Frequency limitations are just one of the policy limitations that can change from group to group under the same insurance company; it is important not to assume a 5 year replacement clause is for all plans under the same insurance.

When a new patient calls your office and wants to make an appointment, one of the questions asked is whether or not dental insurance will be considered as part of the payment of services. The focus is on whether or not there are dental benefits available for this eligible patient. Plan benefit information is available online (if you are contracted) or by direct phone or by fax. Experienced dental business staff know the pitfalls of the benefit statement, because there are many reasons a service listed as a covered benefit may not be paid when submitted.

Many dentists become fed-up fighting with PPO insurance to get paid for what they feel are legitimate claims of warranted services. When it comes to money being paid to dentists, it really boils down to their processing policy, not whether the dentistry is deemed professionally necessary for the patient. Many if not most dentists sign a PPO contract without carefully reading the PPO Processing Policy Manual. Understanding the intended language of the dental plan contract and the processing manual should be required of all employees dealing with processing the procedures and the claims in dental practices.

Claims for dental procedures are processed based on the limitations and exclusions established by the plan document and upheld by the processing policy manual. Most of the time dentists get summaries of the dental plan but patients can get the entire document from their HR or from the payer and pass it on to the dental practice. The processing policy manual can be obtained from the provider relation department or sometimes on the plan website. As in any contract, reading the “fine print” is important, for instance, if a radiograph is determined to be not diagnostic quality or medically necessary, the payer may request a refund.

Filing appeals to the insurance company can be a long and often futile battle, but sometimes the insurance company will review and allow some benefits on a case-by-case basis. It is always recommended to appeal a denial and let your patient know that you are trying to get the claim paid.

For example, a patient claim was filed for a crown on an implant. This was an initial placement crown because the tooth had been extracted and did not have an existing crown on it. The insurance company kept denying the claim saying it had been paid and there weren’t any benefits due to a frequency limitation clause. The patient was disputing the bill and was not paying. The insurance claim agent said repeatedly that the claim was paid for the crown. Finally after more questions and speaking to a supervisor, it was discovered that the crown had been paid but not to the restorative doctor who did the work, it was paid to the surgeon that placed the implant. The restorative dentist ended up being paid by the surgeon and it had a happy ending. 

You will be far more successful navigating the world of dental claim reimbursement if you not only check your patient’s eligibility and benefits, but read the plan’s limitations and exclusions and communicate this to your patients prior to embarking on a treatment plan.

Want to learn more about dental insurance and creating a profitable system for claims in your practice? Sign up for Front Office Training or Office Manager Training today.

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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