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Dental Consultant Tip of The Week

Below is an abbreviated issue of The Huskin Newsletter.  Written by practicing dental consulting it provides updates on the insurance industry and practice management, how to submit claims properly for dental insurance, what consultants are looking for and other valuable information for the practicing dentist.  A 1 year subscription (4 issues/year emailed to you in PDF format) is  $79.  To subscribe, contact us at thehuskingroup@yahoo.com
 
The Huskin Group has a new Dental Consultant website with expanded articles, reports, newsletter and a free subscription to "Dental Consultant Insurance Tips of the Week". 
 
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The Huskin Group

 


Vol. 3 Issue 2

 

 

Cracked Tooth Syndrome

 

 

            Rarely a day goes by without a consultant receiving a claim requesting a crown or onlay for a tooth diagnosed as having Cracked Tooth Syndrome.  Accompanying the request is usually an intraoral photograph on which every existing craze line has been judiciously circled with a pen and labeled as a fracture line. 

            The narrative, if any, states that the tooth is very sensitive to temperature, both hot and cold, and pressure, whenever the patient bites down.  There is usually no history of trauma to this tooth.          If a restoration is present, it is often a moderately-sized amalgam, not large enough to merit placement with a crown or onlay on its own.  Any accompanying x-rays usually show the tooth to be unremarkable in terms of periapical pathology, visible existence of a root fracture, large amount of decay present, periodontal disease, etc..

            How does a dental consultant deal with this abusable but valid clinical situation?

            In the real world, teeth do fracture and crack.

            What indicates to the consultant that this case has merit, that the tooth should be restored with an extra-coronal restoration and this claim or predetermination is not just another ploy to receive benefits for a crown?The consultant is  looking for documentation(a copy of your treatment records and x-rays) of a sequence of treatment demonstrating  that conservative methods were attempted to address the symptoms and rule out other dental conditions before a diagnosis of Cracked Tooth Syndrome was arrived at and full cuspal coverage deemed necessary.

            The consultants want to make sure that conservative measures were attempted, and were unsuccessful, before allowing benefits for an expensive indirect restoration.

            This sequence of treatment they are looking for usually begins with the recording of the patient's initial symptoms, the results of pulp testing, the tooth’s reaction to temperature, reaction to pressure from a bite stick and air testing, removal of any existing restorations to confirm that they themselves are not fractured, inspection after removal of restorations for tooth fracture which might include using a dye or stain, placement of a sedative temporary and finally placement of a full-coverage restoration to see if that indeed will eliminate symptoms.

            The presence of a thorough workup on a tooth will go a long way convincing a reviewer that your diagnosis is valid and requested treatment necessary.

 

 

Maximizing Benefits On Patient Exams

 

            Most offices are aware of patient initial and recall exam frequencies that are found in different insurance contracts and their differences; i.e. two exams per year vs. two exams per year with a frequency limitation of one every six months.

            What most offices do not know is that some insurance companies do not distinguish between the types of exams for which they provide benefits.

            They will pay for only a certain number, usually two, of any type of exam.  And although the benefit levels may vary for eligibility, a time consuming initial and emergency exam is, frequency-wise,  equal to a usually routine recall exam. 

            Therefore, it is important to understand the requirements of an exam as defined by an insurance company  and the needs of your patient so that their visits can be planned to maximize their covered benefits.

            For example, you perform an emergency exam on a new patient that requires you to place a sedative temporary.  A claim is then filed and you receive benefits for both services.  This person returns a week later for a new patient comprehensive exam and associated services.  A claim is filed for that visit also. 

            In certain instances, you may find that the less expensive emergency exam satisfied the patient's contractual frequency which will not entitle you to receive the benefits for the more expensive comprehensive exam.  Although the patient can be billed directly for the service, they have potentially lost benefits if they don't reach their yearly maximum.

            Therefore, proper planning of patient care and their visits is important, especially if specialties are involved.  If you refer an emergency patient out to a specialist for, say, endodontics or periodontics, unfortunately it is often the first one to file a claim that receives the exam’s benefits.

            To avoid this, clearly understand you patient's plan.  This will allow you determine how to file a claim and for what when visit frequency may be important.

            File your claims for the more comprehensive services first and make the patient aware that they will be responsible for the less expensive visits.

 

 

 

PPO Update

 

                Why are certain insurance companies trying very hard to get all the dentists they can to join their PPO network? 

            Everyone knows that  the high cost of dental insurance premiums  are creating the market phenomenon of driving more and more employers into selecting PPO’s (Preferred Provider Organization)  over  traditional indemnity fee-for-service UCR plans for their employees.  Although this type of coverage provides more affordable treatment to the patient, it also restricts the population of treating doctors to those that are willing to accept the lesser PPO schedule of benefits as payment in full. 

            On the recruiting side, the insurance companies are cajoling doctors with the familiar philosophy of “if you have free chair time, a PPO patient with reduced fees is better than no patient at all”.  And an added feature is that with the restricted network size due to a doctor’s reluctant acceptance of lower fees, it means more patients for the doctors that do join.

            And the way many doctors see it is that although the fees are lower, being in this selective network will mean an increased number of   patients for their practice and more billable services which will more than offset the lesser fees. 

            What the companies fail to tell you is that some of them are offering another type of plan to their UCR subscribers who would like  to give the PPO program and their providers a try. 

            It is called an option plan. 

            The network of doctors available to the patient is that company’s PPO providers.  And it is important to remember that most plans only allow a provider to join their PPO(s) if they belong to the indemnity or UCR plan.

            This is the way it works.

            If a subscriber with this option plan is treated by a doctor participating only in the strictly indemnity UCR plan, the doctor receives traditional UCR indemnity fees. 

            But if a participant goes to a  provider who is in both the UCR and PPO plans, the reimbursement is at that PPO or lesser level.

            The end result is that if you join the PPO to increase your patient load with new patients you might suddenly be reimbursed at that lesser level for some of your UCR patients who selected the option and you were previously receiving full benefits for. 

            How can you prevent this from happening if you do decide to participate in a company's UCR and PPO network? 

            First, check your EOB's.  If you find some of your reimbursements from a particular group, including co-payments, have been suddenly reduced, call the plan and ask for an explanation.  If an option plan exists and the group selected it, you might be wise to reconsider being in that PPO. 

            In addition, request a copy of all the plans that are offered by the companies with whom you participate with.  Often, a call to their Professional Relations department will yield this information.  Inspect it carefully to find out if these option plans exist and you are obligated to accept these lower fees just because you participate in both types of networks.  If their PR department is uncooperative,(or doesn't exist), a call to their benefit services or even to the marketing department may be helpful.

            And if this is taking place, you have to weigh the financial impact to your office of terminating from the PPO and potentially losing those patients that have selected that option.  You might be better off accepting and treating less UCR patients but at a fee that is commiserate with your treatment.

 

Coming Soon

 

CDT-3 VS CDT-4

 

There are some significant changes between CDT-3 and CDT-4 which your office should be taking into account when filing dental insurance claims, billing patients and determining fees.  These changes include modifications of certain descriptors and  additions/deletions in the areas of restorative, periodontal and oral surgery.  The Huskin Newsletter will be discussing these changes and how they impact both your practice and the insurance companies in future issues.

 

Boiler Plate Letters to Consultants

How to File for a Single Crown(s)

Filing For Crown Build-ups

Understanding Alternate Benefits

Making Insurance Companies Accept Your Fees

The Future of Dental Insurance

Evidence-Based Dentistry - How It Can Work For You

The views expressed in this publication are the opinions of The Huskin Group.

 

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