When a patient needs a crown, inlay, etc., it is critical to have diagnostic pre-op X-rays, photos, and narratives. This is where your intraoral camera is worth its weight in gold.It’s pretty easy for a plan to determine a benefit when the X-ray shows a tooth with almost all filling and very little tooth structure. It is more difficult (and usually a reason for denial) when the X-ray shows only a small occlusal or two-surface filling. What the plan doesn't see is the fact that the filling is quite large in circumference, or that the large and old amalgam has several cracks in it, the margins are washed out and leaking, and the entire buccal are undermined. This can be documented in your narrative (most doctors don’t bother), but the benefit determination is at the discretion of the claims processor. Photos don't lie and are difficult to dispute. If your claim is denied, you will have to go through the trouble of filing an appeal and requesting a review by a panel dentist. This could cause a delay of four to eight weeks, and this is in addition to the time that has already elapsed since you sent in the first claim. You could, of course, bill the patient, but most offices will hold out on that during appeal.
Is it the patients’ fault if a claim is denied for lack of diagnostics in what would otherwise be an easy determination? You will put in the avoidable position of having an angry patient and a higher-than-necessary outstanding accounts receivable. If this is a replacement crown with open margins, or if it is redecay, I would advise that you ask the doctor if you can take a diagnostic bitewing (no overlaps, and no elongations or foreshortenings. The margins must be crisp and clear) in addition to the required PA.
Since most leaks or open margins are on interproximal surfaces, the bitewing will demonstrate this better than the PA and reduce the chances of an excuse by the plan to deny your claim. If there is an open margin or leakage on a buccal or lingual, then the use of your intraoral camera will substantiate your diagnosis and claim and you should get paid without any delays.
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There are three common classifications of metals when referring to crowns and bridges: High Noble D2790 has at least 40% gold content, Noble D2792 has at least 25% gold content, and Predominantly Base Metal D2791 has less than 25% gold content. Most plan benefits allow for Noble metal.
It is important to know what types of metals your lab is using in order to bill properly. Many overseas labs use a base metal in order to keep costs down. If your lab is using high Noble, you will be paying higher lab fees, therefore you should document and bill accordingly. Keep in mind that in most circumstances, the patient will have a higher co-pay due to the upgrade in metals. If the dentist bills for high Noble and the patient is receiving a Noble metal crown, or if you are billing for Noble metal and your lab uses base metal, the patient isn't actually getting what he or she is being billed for. This can be considered insurance fraud, even if unintentional, so you need to be very careful in this area. The plan may also have exclusions for porcelain on molars. In that case, the patient's co-pays could be higher.
It is extremely important to have a good relationship with your lab tech so the lines of communication are always open. A good lab tech will understand the dentist's needs and always deliver a quality product.
Let’s take a look at this case:
On June 11, preauthorization was sent for D6240 Pontic Porc to High Noble and D6750 Abutment High Noble. The plan was reassigned the codes and approved for D6241 Pontic Porc to Base Metal & D6751 Abut Porc to Base Metal.
When the preauthorization came back, no one noticed that the codes were reassigned to a lesser benefit, or that even though it was “approved,” the patient was well over his max. No one advised the patient what his financial responsibility would be.
The treatment was done with no consent form and no financial arrangements. No one noticed (or spoke up) that the patient and the doctor changed the treatment plan in the chair to an all-ceramic bridge. The insurance paid the claim and the patient later received a bill from the office for several thousand dollars.
What do you think happened next? The patient filed a grievance with his insurance company, and with the dental board for fraud. The doctor was held responsible. The insurance company performed an audit and the doctor was ordered to reimburse the insurance company and the patient. That patient got a high end and beautiful six-unit bridge for free.
That was a pricy error. Let’s look at some things that could have been done to avoid this.
1. Have a dedicated person (and a backup) in charge of following up on preauthorizations. They must read them carefully and understand it completely. They must thoroughly explain the patient’s benefit to the patient and make financial arrangements. It is crucial that this conversation take place before the appointment date. This gives the patient a chance to arrange financing, or if the person needs to reschedule, gives the office time to fill that three-hour gap in the schedule.
2. What role did the chairside team members play? The consent form must be signed after the patient and dentist have reviewed the case. The case should have been discussed in the morning huddle so that if the treatment plan is different from what was done today, that should be apparent and the assistant should have brought it to the immediate attention of the insurance coordinator.
3. Who is entering the treatment? Is there a policy or procedure in place that ensures everything matches and that correct codes are put on the final claim?
Anyone who would like a sample consent form may email [email protected] and put CROWN CONSENT FORM in the subject line.
Theresa Sheppard, RDA, is owner of Optimal Dental Insights. Learn more and contact her at www.careerexpressdental.com.