Worst Claim Story- November 2017

By Jesse Worden, Account Manager

We have a patient who is dual-covered under his own policy with Dental Select and a spouse’s policy with Select Health.  Doctor is in-network with both carriers.  I spotted the apparent error in policy order (Select Health was lister as primary and Dental Select as secondary) and attempted to send treatment to his policy first, only to have Dental Select say they need a primary EOB from Select Health.  Called and spoke with both insurance companies about the issue but they insisted that everything was correct the way it was set up and wouldn’t change anything, and I ultimately figured that as long as both policies are in agreement about the order of payment everything will be OK.  I was so wrong.

Patient was in mid-2015 for SRP.  “Primary” insurance (Select Health) denied two of the quads for lack of medical necessity.  We appealed the claim and received notification from Select Health that they wouldn’t consider all four quads of D4341, even under appeal, but stated they would consider the two denied quads under appeal if we resubmitted those two with D4342 on a corrected claim with an appeal letter.  First appeal was sent and wasn’t received by insurance.  Finally, we were able to get payment on the claim after submitting the appeal again so we could send it to “secondary” (Dental Select), and they paid no problems.  Claims closed.  A few months later (beginning of 2016), we received notification from Select Health that they should have been secondary all along (LIKE I TOLD THEM IN THE BEGINNING!!!) so they retracted every payment they made for claims in 2016, including the appealed SRP claim, and told us to resubmit once Dental Select had paid.  I called and asked if they could delay recollecting the funds until we had EOBs from Dental Select showing they reprocessed as primary, but the rep said they couldn’t do that.  They ended up retracting payments from several bulk remits.  In the meantime, I had sent all the claims back over to Dental Select and they reprocessed as primary, except for one claim (for PAs and BWX) that had been paid in full by Select Health and was not submitted to Dental Select and was past their timely filing deadline at that point.  I spoke with a rep and she told me to send them the claim by email, that they would process it for payment because of the COB error on their end.  I spoke with a rep about this claim just the other day (a couple months after I had originally sent it) and they had record of receiving the email, but the claims department never processed it.  A supervisor has been involved and the claim is supposed to be in processing as we speak.  When we sent the primary Dental Select EOBs back to Select Health with the original Select Health EOBs for processing as secondary, they refused to process the two quads of D4342 (which is what the Select Health EOB shows because that’s how they had us appeal it) because now-primary Dental Select processed them as D4341.  So I had to send the rep ANOTHER corrected claim changing the D4342s back to D4341s.  Finally, when payment was received, Select Health had botched coordination of benefits, shorting the office money on the SRP.  Rather than simply sending the claim back for processing, they required that we launch a formal appeal of the payment decision, which was done and faxed in.  After a couple of months of not hearing anything on the issue, I called and spoke with a rep who was able to locate the faxed appeal and told me that it was received but never acted on.  This was just the other day, so we are STILL waiting for finalization of this fiasco.  The ledger is a complete disaster, as there are adjustments all over the place (correcting entries to negate previous contract reductions, insurance refunds and new contract reductions).  It has been the biggest nightmare I have ever encountered in dental billing, and has made me consider refusing to submit claims for payment in circumstances like this where the coordination of benefits is clearly in error, and instead waiting for the insurance companies to resolve it so that these kind of processing debacles don’t happen.  But ultimately, we are at the mercy of what information the patient chooses to provide (or NOT provide) us at the time of service.  In my experience, coordination of benefits is the single biggest pain to deal with, and this is a classic example of why.

eAssist Helpful News and Billing Tips; Edition #117


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