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It’s not surprising, but the last few weeks have revealed a new insurance attack occurring all across the US. It’s not surprising because this happened a decade ago with Medicine, and even farther back in Pharmacy and Vision. Over the last few years we’ve seen Delta Dental instituting a unilateral lowering of reimbursement and moving Premier coverage out of the picture while reinstating it with a watered-down PPO platform. This is nothing new. Well, welcome now to 2018 and a whole different level of insurance tricks and stalling tactics.

It looks something like this: “Your appeal for the buildups and crowns for Numbers 19 and 20 are denied based on the radiograph and narrative provided there appears to be no missing cusps and adequate tooth structure remaining. According to our guidelines, a crown and buildup can only be allowed when the tooth is extensively decayed and/or has a complete cusp fracture. Therefore, our initial denial is being upheld.”

From this point on, the insurance company is only going to cover a filling (probably an Amalgam filling), and has made you look like a crook in the eyes of your patients. You are also burdened with the lost cost of having done the crown and a patient that is going to go on social media and bad-mouth you and your office. 2018 is ringing in a new age of insurance skullduggery. They have decided that they are OK with an adversarial relationship with “providers” (aka hard-working dentists) and this puts you on a slippery slope. Here is what you can expect:
1. Arbitrary reimbursement while lowering your fees.
2. Coding protocol and audit focus where insurance companies look at a coding statistic and then eliminate all of the doctors from being in network that go over these artificial numbers. Example: They might decide that any doctor doing over 40 crowns a month with them should no longer be contracted with as an in-network provider. It has already happened with some of our clients.
3. Automatic denial of specific procedures: An example would be the crowns referenced at the beginning of this article. They know that a majority of dentists just don’t run their offices like a business, fail to stay adequately informed on the details of the various insurances they accept, and will not challenge them to overturn their decision.
4. Downgrading every treatment to a lower reimbursement level.
5. Postponement of payment and a drawn out back and forth settlement process.

So, what should we do? It is a game that each of us needs to learn and learn quickly. Here is what I have always done and I just don’t get the denials I am seeing in some of our client’s offices. It takes time, systems, and protocols, but you are rewarded in higher, timelier reimbursements and fewer denials.
• We always take pre-op x-rays, and photos of teeth showing the extent of decay, lack of tooth structure, and fractures.
• I always use Charles Blair’s excellent book Coding with Confidence. The trick here is that you need the current coding book for 2018. Then simply use the descriptions of any particular procedure that Dr. Blair uses in his book. From both a medical/legal standpoint, these descriptions for each code in his book are perfect. They leave no room for any grey area. I am also seeing an increase in reimbursement by using the correct code instead of just any code for that procedure. His book makes this simple.
• I seldom, if ever, file a pretreatment estimate ahead of doing the work. The insurance companies know that by delaying their response over 50% of your patients will not follow through with treatment.
• On the day of the prep or procedure, I always remove all of the old filling and any decay (or leave it if it looks horrible) or broken/cracked cusps, prior to doing the prep and take a PA and a photo or two. This always accompanies our insurance submission with no explanation other than it is of that particular tooth. Keep in mind that the reviewer is looking at thousands of submissions in which few go to the effort of supplying any further data. What I find is that seldom are we ever questioned as to the need for the crown. It is obvious to even a washed up old dentist who they have contracted with to just rubber stamp “NO” on any insurance submission you make.
• I always take photos of post-op procedure and of course a finished seated PA of the particular tooth.

I am hopeful that this topic stirs a friendly exchange of ideas between our readers. Please feel free to email me with your suggestions or protocols that have worked in your office. This is how you Summit.

Michael Abernathy, DDS
972-523-4660 cell
[email protected]

PS. As you probably know, the tax laws changed recently. Most people agree that the new law has not simplified things, but has actually further complicated things. Retired dentist Doug Carlsen has been helping doctors with financial matters for many years. I find his insight and advice to be helpful and understandable. You might consider getting on his email list. Below is a link to his latest video (8 minutes) and links to the two articles he makes reference to. (MG)