Dental Insurance Clinical Importance

Transcription

1 Dental Insurance Clinical Importance Mike Weisenfeld, DDS, MPA Bob Rosenthal, DDS DENTAL INSURANCE All dental insurance is based on contracts between a purchaser (company, union, individual) and an administrator (insurance company). Contracts determine what services can receive benefits The Dentist as a Learned Professional Three true learned professions Clergy Law Medicine Learned Professional Needs of others Business person Personal needs 1

2 DENTAL BENEFIT DETERMINATION Is the requested procedure covered under the policy? Does the documentation submitted support the requested procedure? Does the documentation present conditions that contra-indicate procedure requested? DENTAL INSURANCE REALLY THIS IS DENTAL EXPENSE ASSISTANCE DENTAL CONSULTANT DETERMINES BENEFITS 2

3 Confusing Terminology OVERHEAD Accounting definition of Operating Expense vs. Dental definition of Overhead Contract terms vs. care Dental standard of Why can the dental insurance company down-code my dental care but I have to report exactly what I did for the patient? 3

4 Dental Insurance Contract Premiums Claim payment per procedure Maximum amount of reimbursement Maximum Plan Allowance vs. UCR vs. Paid Amount Exclusions Very detailed Cancellations Non-payment of premiums Reserve contribution Payments in the event the company folds Three months of claims and administration costs Review by Dental Consultant The insurance company is at arms-length from the people that review the claims The consultant dentist usually works for the dental review company or is independent USING THE CODE ON DENTAL PROCEDURES AND NOMENCLATURE (CDT CODE) The presence of a CDT code does not mean that the procedure is: Endorsed by any entity Considered a standard of care Covered or reimbursed by a dental benefits plan 4

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8 CROWNS 8

9 PERIODONTAL SCALING and ROOT PLANING D4341 and D4342 This procedure involves instrumentation of the crown and root surfaces of the teeth to remove plaque and calculus from these surfaces. It is indicated for patients with periodontal disease and is therapeutic not prophylactic in nature. 9

10 PERIODONTAL SCALING and ROOT PLANING D4341 and D4342 Root planing is the definitive procedure designed for the removal of cementum and dentin that is rough. PERIODONTAL SCALING and ROOT PLANING D4341 and D4342 Clearly, in order to accomplish RS&P, there must be roots not covered by bone (some recession) When bone level is close to the CEJ, there cannot be RS&P 10

11 CORE BUILDUP D2950 building up of coronal structure when there is insufficient retention for a separate extracoronal restorative procedure. A core buildup is not a filler to eliminate any undercut, box form, or concave irregularity 11

12 CROWN LENGTHENING-HARD TISSUE D4249 This procedure is employed to allow restorative procedure or crown with little or no tooth structure exposed to the oral cavity. CROWN LENGTHENING-HARD TISSUE D4249 is performed in a healthy periodontal environment, as opposed to osseous surgery, which is performed in the presence of periodontal disease. 12

13 IMPLANT TREATMENT COVERED? SURGICAL AND RESTORATIVE? RELATED TO PERIO SURGERY BONE GRAFTING? 13

14 EXTRACTION-ERUPTED TOOTH OR EXPOSED ROOT D7140 Extraction, erupted tooth or exposed root (elevation and /or forceps removal). Includes routine removal of tooth structure, minor smoothing of socket bone, and closure as necessary. SURGICAL EXTRACTIONS D7210 Surgical removal of erupted tooth requiring removal of bone and /or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated 14

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16 PROPHYLAXIS D1110/D1120 Preventive (vs therapeutic) Removal of plaque, calculus and stains from the tooth structures 16

17 BENEFIT DENIAL CONTRACTUAL EXCLUSIONS Failure to pay premium Missing and un-replaced teeth Congenitally missing teeth No alternate benefit allowed 17

18 BENEFIT DENIAL CONTRACTUAL EXCLUSIONS Non-covered service Implants Cosmetic services No evidence of disease or injury Bruxism BENEFIT DENIAL CONTRACTUAL EXCLUSIONS Frequency 5 year rule for crowns 24 months for root planing BENEFIT DENIAL CONTRACTUAL EXCLUSIONS No evidence of disease or injury Placement due to attrition Least costly alternative Many missing teeth Removable vs fixed prosthetics 18

19 BENEFIT DENIAL What to do --- first Control your anger!!! Look at what you sent with claim Does the documentation clearly show what treatment was needed? Are radiographs that you sent of diagnostic quality? Was the proper code used? BENEFIT DENIAL Your response Collect appropriate documentation Contact patient Contact carrier / consultant Today s Dental Insurance Challenges Dental Management Organizations Decreasing Reimbursement Keeping Dentistry a Profession What we can do Knowledge level of dentists Organizing Dental Societies 19

20 Prompt Pay Law Claims must be paid or denied within 30 days Non payment due to non-payment of premium Complaints made to the insurance commissioner must be addressed within 48 hours COMMITTEE ROLE CONTACT NCDS to make appointment with committee for review of your claim. You should bring all materials /records/letters/notes. We will go over all with you. COMMITTEE ROLE IF and WHEN committee determines that an insurance company is systematically denying benefits, inappropriately, we will gather data and try to correct problem. 20