The Huskin Group
Vol. 3 Issue 2
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.
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.
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
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.
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
Future of Dental Insurance
Dentistry - How It Can Work For You
The views expressed
in this publication are the opinions of The Huskin Group.