Is it the patient’s fault if a claim is denied for lack of diagnostic evidence, which would otherwise be an easy determination? You will be in the avoidable position of having an angry patient and a higher than necessary outstanding account receivable. If it is a replacement crown with open margins or if it is caries, I would advise you to ask the doctor if you can do a diagnostic bite (no overlapping and lengthening or shorting. Margins should be crisp and clean) in addition to the required PA .
Since most leaks or open margins are on subsurface surfaces, the sting will prove it better than the PA and will reduce the chances of an excuse from the plan denying your claim. If there is an open margin or buccal or lingual leak, then using the intraoral camera will document your diagnosis and claim and you should be paid without delay.
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There are three common classifications of metals when referring to crowns and bridges: High Noble D2790 has at least 40% gold content, Noble D2792 has at least 25% gold content and mostly Base Metal D2791 has less than 25% gold content. Most program benefits allow Noble metal.
It is important to know what types of metals your lab uses in order to price correctly. Many overseas labs use a base metal to keep costs down. If your lab uses high Noble, you will pay higher lab fees, so you should document and charge accordingly. Please note that in most cases, the patient will have a higher co-pay due to the metal upgrade. If the dentist charges for high Noble and the patient receives a Noble metal crown, or if you charge for Noble metal and your lab uses base metal, the patient is not actually getting what they are charged for. This can be considered insurance fraud, even unintentionally, so you need to be very careful in this area. The plan may also have exceptions for porcelain on molars. In this case, the patient’s contributions could be higher.
It’s extremely important to have a good relationship with your lab tech so the lines of communication are always open. A good lab technician will understand the needs of the dentist and will always deliver a quality product.
Let’s take a look at this case:
On June 11, pre-approval was sent for the D6240 Pontic Porc in High Noble and the D6750 Abutment High Noble. Design recoded and approved for D6241 Pontic Porc to Base Metal & D6751 Abut Porc to Base Metal.
When the pre-authorization came back, no one noticed that the codes were reassigned to a lower benefit or that even though it was “approved,” the patient was well over the maximum. No one informed the patient what his financial responsibility would be.
The treatment was done without a consent form and without financial arrangements. No one noticed (or talked about) that the patient and doctor changed the chairside treatment plan on an all-ceramic bridge. The insurance paid the claim and the patient later received a bill from the office for several thousand dollars.
What do you think happened next? The patient filed a fraud complaint with his insurance company and the dental board. The doctor was held responsible. The insurance company audited and the doctor was ordered to reimburse the insurance company and the patient. This patient received a beautiful high-quality six-unit bridge for free.
This was a pricing error. Let’s look at some things that could have been done to avoid this.
1. Have a dedicated person (and a backup) responsible for monitoring pre-approvals. They should read them carefully and fully understand it. They must thoroughly explain the patient’s benefit to the patient and make financial arrangements. It is critical to have this conversation before the date of the appointment. This gives the patient an opportunity to arrange funding or if the person needs to reschedule, it gives the office time to fill that three hour gap in the schedule.
2. What role did the members of the president’s team play? The consent form must be signed after the patient and the dentist have reviewed the case. The case should have been discussed in the morning chat so that if the treatment plan is different than what was done today, that should have been seen and the assistant brought it to the attention of the insurance coordinator immediately.
3. Who enters treatment? Is there a policy or process that ensures everything matches and correct codes are placed on the final claim?
Anyone who wants a sample consent form can email [email protected] and put WREATH COLLECTION FORM in the subject line.
Theresa Sheppard, RDA, is the owner of Optimal Dental Insights. Learn more and contact her at www.careerexpressdental.com.
