Insurance Connection
The Code One dentist ’ s thoughts on the importance of understanding the ADA code and how insurance companies ’ policies relate to the code .
By Dr . Tad Glossner Chair , Dental Benefits Committee
“ This build up and electro surgery you did on tooth number 30 for Mr . Smith was denied by the insurance company and we can ’ t collect anything from the patient .”
These , and similar statements from my insurance coordinator , have become the basis of many of my recurring nightmares from which I awake in a cold sweat , sitting straight up in bed , with gritted teeth , a racing heart and the desire to choke a grizzly bear . That is , of course , as long as that grizzly bear worked for any number of insurance companies whose payment policies are more complicated and illogical than the assembly instructions for a 5-year-old ’ s first bicycle . Why can ’ t they just simply allocate funds to expertly-completed procedures done by qualified dentists for properly-diagnosed conditions ? These are two of the many insurance related questions that haunt me .
Now , you have to understand that I am very unlike most of the dentists I know . I have this crazy idea that I am the one who went to dental school and spent lots of borrowed money to do so . I learned how to properly diagnose the conditions . I learned how to expertly complete the procedures to treat those diagnoses . I took and passed the appropriate tests necessary to be properly licensed to practice this great profession in this great state . Nowhere in my education did my professors tell me that learning insurance companies ’ policies was paramount to my successful practice of dentistry . Therefore , why should I concern myself with the insurance companies ’ policies at all ? They should pay me for what I do and not question my diagnoses .
Now , keep in mind that I understand that my thinking is completely uncharacteristic of everyone reading this article … or maybe not . Maybe , just maybe , you have thought or have heard a colleague say that he or she doesn ’ t believe that it is his / her / your responsibility to know whether or not an insurance company is going to cover a procedure or at what level that coverage may or may not be . I wonder , have you ever gone shopping and asked a customer service representative how much something was going to cost ? How likely would you be to buy that item if that customer service representative ’ s answer was , “ It ’ s not important what it costs , ( i . e . I don ’ t know what your insurance company will say ), it ’ s just important that you need it ?”
So , back to Mr . Smith ’ s tooth number 30 . Had I spent the time to learn and understand that Mr . Smith ’ s insurance company has a policy not to pay for any gingival procedure in conjunction with a restoration , and that they don ’ t approve payment for build ups without an intraoperative periapical radiograph that demonstrates sufficient tooth loss to necessitate a build up , I could have treated Mr . Smith a little differently . I could have referred Mr . Smith to a periodontist for crown lengthening or done it myself . Obviously , this would have been best accomplished following a preauthorization so that Mr . Smith knew how much his insurance was going to pay and , more importantly , how much he was going to have to pay . Or , alternatively , I could have done the electro surgery , knowing full well that it needed to be done and that I wasn ’ t going to be reimbursed for it . Ultimately , if I am honest with myself , my lack of knowledge created a great deal of stress and unhappiness in my life , but I wasn ’ t the only one affected .
So , let ’ s review how many people in my life were negatively affected by my apathy toward Mr . Smith ’ s insurance company ’ s policies . First and foremost , I was negatively affected . After all , it is me who will not be reimbursed . Then there is my receptionist to whom I dictated three letters to the insurance company in our three fruitless appeals , taking valuable time from her other duties and ultimately making her job more difficult and stressful . Next is my insurance coordinator , who has told me many times that I should consider looking at the insurance guidelines for the procedures because payment happens quicker when the procedures are actually covered and the proper documentation is sent the first time . Her multiple requests for me to understand this has taken valuable time from her other tasks , ultimately making her job more difficult and stressful as well . I can ’ t forget to mention my accounts receivable coordinator , who has had to remember to pull Mr . Smith ’ s
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July / August 2011 • Pennsylvania Dental Journal
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