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Dave's Insurance Question

Dave, it’s good to hear from you.  I hope my reply to your question helps.

Any input on Delta Dental refusing to pay for crowns? For the last month they are refusing to pay for crowns; we have never had this issue before. I spoke to 3 other dentists that confirmed our experience.

I am checking with some of the bigger groups to see if they are being treated differently.

How does one deal with this kind of situation? He who holds the gold makes the rules.


Dave, it’s good to hear from you.  I hope my reply to your question helps.  Sorry it is a little long.  I think you will find it informative.  Follow the steps.  Leave nothing out.  Do it every time this happens, and watch the fun begins.

Welcome to “the new emerging economy” where insurance companies and banks create the rules. There is a way to bring them into line, but it takes a very intentional and consistent action from your office, the insurance company, and the insured. I have attached a letter we have used for almost ten years in order to sway the control of benefits back into our offices hands. While insurance companies are the gateway and controllers of how and when and even if you are paid, they also have fiduciary responsibilities that they must meet in order to continue to operate as an insurance company in your state. What makes this work, is the systematic follow up, preceded by a very calculated way of submitting your claims, and the implementation of this letter. Insurance companies know that 70% of all insurance “pre-determinations” end with the patient not following thru with treatment. No indemnity insurance plan can make you do a predetermination. They will have to pay all valid claims regardless of a predetermination. Managed care plans (HMO or PPO) will most likely have a contractual agreement that requires you to first receive an acknowledgment of coverage prior to the delivery and subsequent payment of any claim. Insurance companies were never worried about their relationship with you the doctor. Their rating as an insurance carrier is based solely on the feedback they and the insurance commission from your state receive from the insured. This is where the letter comes in. All of our insurance submissions are sent with pre-op photo, pre-op xray, post op photo and xray after the old amalgam filling, or fractured cusp or decay is removed, a photo and xray of the build up, and xray of the final seat. They are sent unlabeled, with the exception of the patients name and tooth number. This is important. By not sending or labeling the pre-op versus post op, the incompetent worthless 19 year old reviewer or washed up dentist has to actually study the information that has been sent to them. Most times they are so incompetent that they assume that the post amalgam (decay or fracture) film is the pre-op xray and photo and pay immediately. If they don’t pay, there is absolutely no grounds to deny the claim based on lack of information and the delay it creates in order to supply the insurance company with further xrays and details. It wouldn’t surprise me that most insurance companies delay payment by requesting further information as SOP in order to hang on to the money a few months longer and therefore invest it for a greater return before even considering the facts of your claim. Longer delays equal more money for the insurance company.  Doing this eliminates the number one delaying tactic we see insurance companies employing in order to delay payment. Keep in mind that we are assuming that you are taking advantage of digital xrays, digital cameras, and digital transmission of claims to shorten the already drawn out process that snail mail creates in the submission of claims.

Secondly, we are assuming that you are using a simple old school accordion file with 30 tabs labeled 1 thru 30 to represent the days of a month.  This can be acquired from any office supply company.  While I am a big fan of digital everything, we have found that this old school follow up system is so simple and complete as to eliminate the need for talented staffing in this area.  Here is how it works.  Each time that you submit an insurance claim or pre-determination, the processor creates a sheet of paper confirming your successful transmission of the claim and attached information.  This paper is placed in the file on the day of the month that it was received.  As an example, if it is the fifth of the month, then the tracking sheet would be placed under the number 5.  In this way, when the fifth of next month rolls around or in about thirty days, you would arrive at work, pull all of the tracking sheets for that day (it is now one month later) and every insurance company would be contacted by phone to verify the receipt, and current condition of the payment of that claim.  This information is noted on the tracking sheet and this is where the letter comes in. In this way your insurance follow up might only take an hour or less a day.  There will be some that have paid and would be discarded.  You then take action on the claims that need follow up daily.  You never put or transfer action till the next day.  You never put off taking action until it is 90 days overdue.  This is a system and is the most important duty that this staff member has until it is completed.  This creates a systematic way to insure a steady daily cash flow for your practice overhead.

Next save the letter in this email as a “template” in your word documents so that it may be opened and the patient’s name, insurance company, details of treatment and documentation can be attached.  This letter is best sent by email and registered mail with receipt signature required.

It is sent to the patient and insurance company.

Re:  Patient:



Treatment Dates —– Prep: ____________     Seat: ____________



Dear Director of Claims:

It is our understanding that this claim was denied pursuant to your decision that the care given was not dentally necessary.

The explanation of benefits did not give adequate information to establish the accuracy of this decision.  Therefore please provide the following information to support the denial of benefits for this treatment.

Please furnish the name and credentials of the insurance representative who reviewed the treatment records.  Also, please provide an outline of the specific records reviewed and a description of any records which would be necessary in order to approve the treatment.

Further, we would appreciate copies of any expert dental opinions which have been secured by your company in regards to treatment of this nature and its efficacy so that the treating dentist may respond to applicability to this patient’s condition.



Cathy Armon

Office Manager

Attn: We are resubmitting the claim with additional information.  An approval of this claim will negate the necessity of the paperwork requested.  A further denial of this claim will require all the records and information requested within the time specified in the applicable Texas Statutes.  A copy of this letter is also being forwarded to the patient and the Texas Insurance Commission for their review.


The third and most important step is to create a letter in template form from the patient on non-office stationary stating that:  “Even though,  Doctor Good Heart has sent xrays, photos, and complied with any and all requests from their insurance company in a timely fashion (Use their name, address, contact names, and a copy of all documentation), the insurance company has purposely delayed or failed to pay for my necessary treatment.  I would like to file a formal complaint against this insurance carrier and open an investigation about why they have delayed and/or failed to perform on their legal obligations.”  With this letter the Insurance Commission, like the state board when it receives a complaint, is required by law to open an investigation of the allegations whether they have merit or not.  This creates a small ripple that will become a tsunamionce they have 5 or 10 complaints pending against them.  Think what it would do if you forwarded this email to 10 of your dental buddies and they started calling the insurance companies bluff.  Imagine the backlog and increased staffing hours it will create in order to supply the information and follow thru.  What will the confrontation with each states insurance commission create in ill will with employers when they find out that their insurance companies can no longer write policies for them?  This letter should be drawn up by you with all the supporting documentation and have the patient sign it and you send it to the insurance company and the insurance commission by registered mail and signature return.  Just wait and see what happens.

For the first time the insurance company will be faced with possible sanctions by the commission, especially if you are diligent to do this every time.  It affects their rating as a company, their ability to negotiate contracts with employers, and creates an entirely different relationship between you and the insurance company.  You are no longer the victim.  They no longer will be able to treat you the doctor as an annoyance and second class citizen.  You have now effectively created an adversarial position between the insurance company and the people that make it possible for them to continue doing business.  You have shifted the blame of non-performance from you, the real victim, to them, the bully on the play ground.  It will be like turning on the lights at night in the kitchen and watching the cockroaches scatter.  Imagine the repercussions an insurance company would have if they tried to do anything in response to your legal request other than comply.

I know this takes time.  I know it is an added expense.  It is the one and only recourse you have to bring the insurance companies back into line and accountable for their actions.  Do this and watch how more efficiently your claims are processed as opposed to the dummy down the street that continues to play by the rules that insurance companies arbitrarily create and change in order to keep you the doctor off  balance.

Michael Abernathy DDS