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Thursday Troubleshooter: Why can dental insurance companies down code?

Oct. 3, 2019
This dental practice staff is frustrated that insurance companies can down code, often without much explanation. What can they do about it?

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QUESTION: I just read an article about insurance companies downcoding or remapping codes. A statement made was: "Why can a carrier remap (down code) but a practice cannot? When a carrier remaps, it is based on a contract and finances. When an office remaps, it’s saying it performed a different procedure. That change can be considered fraud, whether it’s from ignorance or by accident."

This to me does not answer the question about why it is acceptable for an insurance company to downgrade. If treatment performed by a dentist is accurately reported with supporting documents, why would the insurance company not only be allowed to down code, but to tell the dental office that it cannot bill the patient?

For instance, take 9110 versus 3332. These are completely different procedures, performed for different reasons in different circumstances. One insurance company believes it has a right to decide that the doctor reported incorrectly (which is not the case), and it therefore downgrades the code and refuses to pay the proper benefit. Please advise us on this subject. We would sure appreciate it!

ANSWER FROM PATTI DiGANGI,  founder of DentalCodeology:
Remapping is a difficult and, to be honest, seemingly unfair concept. There are a few more terms needed for you to understand how this works. 

Dental benefits are based on a contract between two parties, often an employer and a carrier. It can also be between a practice and a carrier. Coverage or noncoverage is not based on the whim of the carrier, it’s based on the contract. It’s questionable whether each party understands all the language in that contract.

Something that can be written into a contract is a LEAT clause, which means least expensive alternative benefit. It is a type of cost containment measure used by many carriers. Under this clause, when there are multiple viable options for treatment, the plan will only pay the least expensive. The ADA has published a document called “Least expensive alternative treatment clause written from both the dentist and carrier’s points of view that explains this in greater detail.

As far as the carrier telling a practice they cannot bill something to a patient, this is also a contractual agreement. A carrier does not have the right to determine treatment. Further, a carrier cannot dictate how a practice decides to bill unless that practice has signed an agreement. A carrier does have the right to determine payment under a contract.

Contracts are often signed by one person, but the administration of the contract is performed by someone else. Further, that person never sees the contract signed. And finally, whether the signer or administrator understands all the legalese in the contract can be questionable. 

In my experience, contracts generally favor those bringing it. So, do contracts favor what the carrier wants? Absolutely, this is their business. Carriers use numbers, tables, and actuaries (specialists who have a deep understanding of math, statistics, and business management) to figure out policies based on risk. What is the process a practice uses to decide to sign a contract? 

Contracts are serious documents with legal ramifications. The ADA Center for Professional Success provides guidance with its “What every dentist should know before signing a dental provider contract and contract analysis service, which are free to ADA members.

When a carrier remaps, does the carrier keep a record of what a practice submitted? Metrics can give the power to quickly arrive at data-driven decisions that can improve outcomes and performance, drive cost savings, and enhance patient quality of care and satisfaction. Currently, carriers hold more data on treatments being performed than any other source. If the carrier remaps, is the data accurate? Metrics and measurability are important business concepts. Practices are required to code accurately and completely. This is important to patients as well as to the bigger picture.


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