QUESTION: I’ve been trying to find definitive answers on how to deal with insurance companies' down coding, as well as when they completely change ADA codes. Here’s an example: MetLife changed D5226 to D5650, a mandibular partial denture to adding a tooth to a denture. Our fee was $1,225 and MetLife allowable for the D5650 was $116. I want to know how to deal with insurance companies downgrading composite resin to amalgam and reducing the allowable. I’m willing to take a course or do whatever’s necessary to learn what our rights are legally and how much control we have over the insurance companies. I recently took a course through National Provider Compliance Corporation (NPCC) and it was a scam. They wanted participants to purchase all their material for $900. I did make a copy of the example letter to send to the insurance companies to negotiate our fees, so at least that was helpful. Thank you for any help you can provide.
ANSWER FROM PATTI DIGANGI, coauthor of the “DentalCodeology," series of books:
You are not alone in your questions and woes in this area. You have a couple different and related issues here. Let’s start with downcoding. For a long time I didn’t understand why an insurance carrier can downcode and it is OK, yet if a practice does this it can be considered insurance fraud. Let’s start with a couple of definitions:
• Downcoding—A practice where a benefit code has been changed to a less complex and/or lower cost procedure that was reported.
• Upcoding—Reporting a higher level of dental service than was actually performed.
Carriers can legally downcode because they are paying according to the contract. They are not changing the treatment provided. Practitioners can only code for care provided.
The second issue is dealing with insurance companies. Your role varies based on the choices and agreements your practice may or may not have made with any carriers or plans. What you don’t have is control over the carriers, nor do they have it over you. It isn’t about control, it’s about the terms of a contract. If you have signed a contract, then the problem might be in understanding the terms of what was signed. Do carriers make mistakes in adjudicating claims? Yes. Your example “D5226 to D5650, a mandibular partial denture to adding a tooth to a denture” sounds like someone at the carrier made a mistake. Ask for an explanation and challenge these errors. Do practices make mistakes with coding submitting claims? Yes, which is why you’re seeking guidance. What doesn’t need to happen is to see the carriers as enemies, or friends. A contractual relationship is just that—a contract that has been negotiated and has terms with all sides doing what they can to advance their own best interests.
If you have signed no contracts with any carriers, and even if you have, the best way to deal with them is to do everything you can to help optimize payment and then let it go. The existence of code does not mean a patient has coverage under a policy. Yet without a code no coverage could be offered. This is where confusion lies. Codes and coverage are related but not the same. The role of the practice is to use the most accurate codes for all procedures performed for possible coverage under a policy.
The best way to optimize coverage is routine documentation of dental-medical necessity. Dental-medical necessity is different from person to person and changes over time. There is benefit to all practices to document it routinely to help optimize dental benefit coverage and cross-coding opportunities. In the 1/14/16 TroubleShooter, I talked about Twitter-style documentation of dental-medical necessity.
There are many reputable resources to help you learn more. The best way to find answers is to talk with others on a similar journey. I’m a member of the American Association of Dental Office Managers (AADOM), the nation's largest educational and networking association dedicated to serving dental practice management professionals. Their mission is to provide networking, resources, and education to help achieve the highest level of professional development.
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