Worker’s Compensation Should be Easy to Get… Right?
My worst claim story is for a worker’s compensation claim for a patient that had an accident in 1970. The patient had to have major facial reconstruction. He lost all of his teeth on the lower arch. He has a subperiosteal implant that retains a full lower denture. He needs to visit an oral surgeon at least once a year for maintenance, component changes, and surgical gingivectomies around all implant parts, since it is subgingival it tends to grow a lot of granulation tissue. The claim had to be submitted by mail as this was a union plan backed by medicaid since the patient is now retired. It was consecutively denied for 6 months stating they needed more information. When I would call, the Union would tell me that they don’t have access to denial codes and did not know how to reach out to Medicaid. I continued to send all available information. Finally Medicaid contacted the provider a year later stating they would not pay due to timely filing limitations. That took three months of appeals and copies of claims and letters I had been sending for months. After three months they responded with an explanation that they do not cover any implant related services. I continued to submit appeals on a monthly basis. I reached out to the patient and explained the situation. The patient and the provider were owed these benefits. Due to his worker’s compensation status and history, he is entitled to receive treatments related to his injury for the remainder of his life. The patient called and they too ignored his requests. I finally mailed him diagrams, pictures, and explanations of what a subperiosteal implant is, how it works, and why he needed the treatment. The patient then went to the union, personally handed my appeals and it was processed on the spot! It turns out that the reviewing providers for both the Union and Medicaid did not know what a subperiosteal implant was and had never seen anything like it before so they would deny it as a non covered service. It took us 18 months but all $6,000 were paid in full with $75 in interest. Persistence wins!
Dental Billing Tips and News for Pros; Edition #146