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Are​ ​Dental​ ​Benefits​ ​Available​ ​for​ ​my​ ​Crown?

When​ ​a​ ​new​ ​patient​ ​calls​ ​your​ ​office​ ​and​ ​wants​ ​to​ ​make​ ​an​ ​appointment,​ ​one​ ​of​ ​the​ ​questions asked​ ​is​ ​whether​ ​or​ ​not​ ​dental​ ​insurance​ ​will​ ​be​ ​considered​ ​as​ ​part​ ​of​ ​the​ ​payment​ ​of​ ​services. The​ ​focus​ ​is​ ​on​ ​whether​ ​or​ ​not​ ​there​ ​are​ ​dental​ ​benefits​ ​available​ ​for​ ​this​ ​eligible​ ​patient.​ ​​ ​Plan benefit​ ​information​ ​is​ ​available​ ​online​ ​(if​ ​you​ ​are​ ​contracted)​ ​or​ ​by​ ​direct​ ​phone​ ​or​ ​by​ ​fax. Experienced​ ​dental​ ​business​ ​staff​ ​knows​ ​the​ ​pitfalls​ ​of​ ​the​ ​benefit​ ​statement​ ​because​ ​there​ ​are many​ ​reasons​ ​a​ ​service​ ​listed​ ​as​ ​a​ ​covered​ ​benefit​ ​may​ ​not​ ​be​ ​paid​ ​when​ ​submitted. Many​ ​dentists​ ​become​ ​fed-up​ ​fighting​ ​with​ ​PPO​ ​insurance​ ​to​ ​get​ ​paid​ ​for​ ​what​ ​they​ ​feel​ ​are legitimate​ ​claims​ ​of​ ​warranted​ ​services.​ ​​ ​When​ ​it​ ​comes​ ​to​ ​money​ ​being​ ​paid​ ​to​ ​dentists​ ​it​ ​really boils​ ​down​ ​to​ ​their​ ​processing​ ​policy​ ​not​ ​whether​ ​the​ ​dentistry​ ​is​ ​deemed​ ​professionally necessary​ ​for​ ​the​ ​patient.​ ​​ ​Many​ ​if​ ​not​ ​most​ ​dentists​ ​sign​ ​a​ ​PPO​ ​contract​ ​without​ ​carefully reading​ ​the​ ​PPO​ ​Processing​ ​Policy​ ​Manual.​ ​​ ​Understanding​ ​the​ ​intended​ ​language​ ​of​ ​the​ ​dental plan​ ​contract​ ​and​ ​the​ ​processing​ ​manual​ ​should​ ​be​ ​required​ ​of​ ​all​ ​employees​ ​that​ ​are​ ​dealing with​ ​processing​ ​the​ ​procedures​ ​and​ ​the​ ​claims​ ​in​ ​dental​ ​practices. Claims​ ​for​ ​dental​ ​procedures​ ​are​ ​processed​ ​based​ ​on​ ​the​ ​limitations​ ​and​ ​exclusions​ ​established by​ ​the​ ​plan​ ​document​ ​and​ ​upheld​ ​by​ ​the​ ​processing​ ​policy​ ​manual.​ ​​ ​​ ​Most​ ​of​ ​the​ ​time​ ​dentists get​ ​summaries​ ​of​ ​the​ ​dental​ ​plan​ ​but​ ​patients​ ​can​ ​get​ ​the​ ​entire​ ​document​ ​from​ ​their​ ​HR​ ​or​ ​from the​ ​payer​ ​and​ ​pass​ ​it​ ​on​ ​to​ ​the​ ​dental​ ​practice.​ ​​ ​The​ ​processing​ ​policy​ ​manual​ ​can​ ​be​ ​obtained from​ ​the​ ​provider​ ​relation​ ​department​ ​or​ ​sometimes​ ​on​ ​the​ ​plan​ ​website.​ ​​ ​As​ ​in​ ​any​ ​contract, reading​ ​the​ ​“fine​ ​print”​ ​is​ ​important,​ ​for​ ​instance,​ ​if​ ​a​ ​radiograph​ ​is​ ​determined​ ​to​ ​be​ ​not diagnostic​ ​quality​ ​or​ ​medically​ ​necessary​ ​the​ ​payer​ ​may​ ​request​ ​a​ ​refund. Filing​ ​appeals​ ​to​ ​the​ ​insurance​ ​company​ ​can​ ​be​ ​a​ ​long​ ​and​ ​often​ ​futile​ ​battle​ ​but​ ​sometimes​ ​the insurance​ ​company​ ​will​ ​review​ ​and​ ​allow​ ​some​ ​benefits​ ​on​ ​a​ ​case​ ​by​ ​case​ ​basis.​ ​​ ​It​ ​is​ ​always recommended​ ​to​ ​appeal​ ​a​ ​denial​ ​and​ ​let​ ​your​ ​patient​ ​know​ ​that​ ​you​ ​are​ ​trying​ ​to​ ​get​ ​the​ ​claim paid. For​ ​example,​ ​a​ ​claim​ ​was​ ​filed​ ​for​ ​a​ ​patient​ ​for​ ​a​ ​crown​ ​on​ ​an​ ​implant.​ ​This​ ​was​ ​an​ ​initial placement​ ​crown​ ​because​ ​the​ ​tooth​ ​had​ ​been​ ​extracted​ ​and​ ​did​ ​not​ ​have​ ​an​ ​existing​ ​crown​ ​on it.​ ​​ ​The​ ​insurance​ ​company​ ​kept​ ​denying​ ​the​ ​claim​ ​saying​ ​the​ ​claim​ ​had​ ​been​ ​paid​ ​and​ ​there weren’t​ ​any​ ​benefits​ ​due​ ​to​ ​a​ ​frequency​ ​limitation​ ​clause.​ ​The​ ​patient​ ​was​ ​disputing​ ​the​ ​bill​ ​and was​ ​not​ ​paying.​ ​​ ​The​ ​insurance​ ​claim​ ​agent​ ​said​ ​repeatedly​ ​that​ ​the​ ​claim​ ​was​ ​paid​ ​for​ ​the crown.​ ​​ ​Finally​ ​after​ ​more​ ​questions​ ​and​ ​speaking​ ​to​ ​a​ ​supervisor​ ​it​ ​was​ ​discovered​ ​that​ ​the crown​ ​had​ ​been​ ​paid​ ​but​ ​not​ ​to​ ​the​ ​restorative​ ​doctor​ ​who​ ​did​ ​the​ ​work,​ ​it​ ​was​ ​paid​ ​to​ ​the surgeon​ ​that​ ​placed​ ​the​ ​implant.​ ​​ ​The​ ​restorative​ ​dentist​ ​ended​ ​up​ ​being​ ​paid​ ​by​ ​the​ ​surgeon and​ ​it​ ​had​ ​a​ ​happy​ ​ending.  You​ ​will​ ​be​ ​far​ ​more​ ​successful​ ​navigating​ ​the​ ​world​ ​of​ ​dental​ ​claims​ ​reimbursement​ ​if​ ​you​ ​not only​ ​check​ ​your​ ​patient’s​ ​eligibility​ ​and​ ​benefits​ ​but​ ​read​ ​the​ ​plan’s​ ​limitations​ ​and​ ​exclusions and​ ​communicate​ ​this​ ​to​ ​your​ ​patients​ ​prior​ ​to​ ​embarking​ ​on​ ​a​ ​treatment​ ​plan.


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