© 2012 American Dental Association. All Rights Reserved
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Contracts, Coding and
Claims
Montana Dental Association
May 2, 2013
2
To be addressed –
I. Non-Par Issues with Third-Party Carriers
II. Contract Issues
III. Payer Cost Containment Methods
IV. Preventing & Resolving Claim Errors
V. Common Claim Denials
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2012 American Dental Association. All Rights Reserved
3
Non-Par – Assignment of benefits
Patient’s signed request ignored – pay
patient directly
> Carriers claim it is their prerogative to honor
assignment
> It is a network provider “perk”
Problem for dental office – patient holds the
money
> May not pay the bill sent by the office
©©2012
2012 American Dental Association. All Rights Reserved
4
Non-Par – More patient out-of-pocket
Greater patient out-of-pocket expense with
non-par
> Higher deductible & lower annual maximum
> Lesser per-procedure reimbursement amount
Non-par dentist at a distinct disadvantage
> Patient’s potential higher out-of-pocket
expense
Intent is to steer patients to par dentist
©©2012
2012 American Dental Association. All Rights Reserved
5
Non-Par – Failure to receive EOB
Many carriers send EOBs only to patients
and participating dentist offices
> Claim this is a benefit of being a par dentist
Causes problems for the non-par office –
need EOB to:
> Assist patients with questions about
reimbursement amount
> Address inappropriate messages
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2012 American Dental Association. All Rights Reserved
6
Non-Par – Faster payment for discounts
Goal – persuade dentist to accept lower
amount for faster payment
> Action by intermediaries on behalf of the thirdparty payer
If contacted determine if the discount is –
> A one-time arrangement
> Continuing without additional consent
ADA’s contract analysis service can assist
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2012 American Dental Association. All Rights Reserved
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2012 American Dental Association. All Rights Reserved
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2012 American Dental Association. All Rights Reserved
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2012 American Dental Association. All Rights Reserved
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Contract – “All Affiliated Carriers” clauses
May be part of participating provider
contract
If contract is signed the dentist becomes a
participating provider of the –
> Third-party payer offering the contract
> Any affiliate, even if not specifically named
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2012 American Dental Association. All Rights Reserved
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Contract – National processing policies
Par dentist may have agreed to abide by
payer's national processing policies
> Policies may not appear in the contract, only
incorporated by reference
Policies may be posted on payer’s Web site
> Describe how every dental procedure code is
adjudicated
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2012 American Dental Association. All Rights Reserved
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Contract – Component / Denied procedures
Patient cannot be billed for procedures that
the payer considers incidental to other
procedures
When procedures are disallowed it means
that the plan –
> Does not cover the procedure
> May not allow the dentist to charge the patient
for the procedure
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2012 American Dental Association. All Rights Reserved
13
Contract – Provider Relations contacts
Problem resolution requires access to
qualified payer staff
Dentist to dental consultant contact at
professional level enables
> Rapid problem resolution
> Timely claim adjudication and payment
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2012 American Dental Association. All Rights Reserved
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Contract – Removal from network lists
After ending par-provider status change has
not been made public (e.g., Internet)
Raises issues for patients and dentists
> Appointments scheduled then cancelled when
patient learns dentist is no longer in network
> Resolving patient objections to balance billing
or billing for services at dentist’s full fee
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2012 American Dental Association. All Rights Reserved
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2012 American Dental Association. All Rights Reserved
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Cost Containment – aka “Managed Care”
Intended to reduce or eliminate a benefit
plan’s financial exposure
Before patient receives care the benefit
plan sponsor and payer should explain:
> All limitations, exclusions and other cost
containment measures (e.g., in & out of
network)
> Application of deductibles, co-payments,
coinsurance and balance billing
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2012 American Dental Association. All Rights Reserved
18
Containment – Annual maximums
Total dollar amount available to fund a
patient’s necessary dental care
> May only cover a portion of costs for necessary
care
Dental plan reimbursement annual
maximums commonly $1,000 to $1,500
> Higher annual maximums are rare
Annual maximums are said to be market
driven
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2012 American Dental Association. All Rights Reserved
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Containment – LEAT provisions
Least Expensive Alternative Treatment
> Reduces benefits to the least expensive of
other treatment options determined by the
benefit plan
> Dentist may recommend a fixed denture – but
plan may allow reimbursement only for a
removable partial denture
A pretreatment estimate may be helpful to
prevent patient confusion
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2012 American Dental Association. All Rights Reserved
20
Containment – Bundling procedures
Systematic combining of distinct dental
procedures that results in a reduced benefit
for the patient/beneficiary
Radiographs are a common example
> Panoramic image and bitewings may be
combined and recoded as a full mouth series
(FMX)
> Future D0210 claim is then subject to benefit
plan frequency limitations (e.g., 1 FMX every 5
years)
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2012 American Dental Association. All Rights Reserved
21
Containment – Downcoding
Payer changes procedure code on claim to
a less complex or lower cost procedure
> May interfere with dentist-patient relationship
unless EOB states it is only due to a business
reason
Carriers typically do not disclose their
downcoding, or bundling, policies during the
contract negotiation process
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2012 American Dental Association. All Rights Reserved
22
Containment – Exclusions
Many dental plans do not provide coverage
for all dental procedures
> This does not mean that the services are not
necessary
Prepare a treatment plan based on the
patient’s clinical needs
> Patient acceptance of a treatment plan is often
influenced by available benefits
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2012 American Dental Association. All Rights Reserved
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Containment – Plan frequency limitations
Some procedures covered only at stated
intervals, commonly –
> Cleanings and examinations twice in a planyear or once every six months
> Intraoral – complete series radiographs once
every 5 years
> Bitewings once every 6 months
> Crowns once every 5 years
©©2012
2012 American Dental Association. All Rights Reserved
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Containment – Not dentally necessary
Clauses that state only medically or dentally
necessary procedures are covered
> If claim denial does states services are
inappropriate or not medically necessary – may
be an ethical issue with the dental consultant
> Dental consultant does not have enough
information to make a diagnosis
> Should limit denial language to not payable
under the dental plan
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2012 American Dental Association. All Rights Reserved
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Containment – Predetermination
Sometimes required when charges
expected to exceed a certain dollar amount
Not a payment guarantee – dollars may be
used for other services by another dentist
before predetermined procedure delivered
Returned with the following information:
> Patient’s eligibility and covered service
> Deductible, co-pay and amount payable
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2012 American Dental Association. All Rights Reserved
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Containment – Deductibles
Amount of a dental expense that is the
patient’s responsibility
Due before a third-party payer assumes any
liability for payment of benefits
May –
> Be an annual or one-time charge
> Vary in amount from program to program
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2012 American Dental Association. All Rights Reserved
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Containment – Pre-existing conditions
Restriction on coverage for dental
conditions present before an individual’s
enrollment in the plan
> Some plans may never cover a pre-existing
condition
> “Waiting period” of varying length before
coverage is available
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2012 American Dental Association. All Rights Reserved
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Containment – UCR
Misleading acronym for 3 different concepts
> Used by a dental plan to describe its own fee
reimbursement schedule
No universally accepted method for
determining the maximum plan benefit
> Each company creates its own – and can vary a
great deal among plans in the same area
> Company’s maximum plan benefit may be lower
than area dentists’ full fees for the same service
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2012 American Dental Association. All Rights Reserved
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Containment – Payment reductions
At least three major carriers have reduced
maximum allowable fees for participating
providers
Provisions for unilateral reduction are in
current and new contract forms
When notified of a reduction a dentist may
negotiate fees on an individual basis
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2012 American Dental Association. All Rights Reserved
30
Containment – Reclassify & Cost Shift
Reimbursement for extractions needed prior
to orthodontic treatment
> Some carriers now allocate to the limited
lifetime orthodontic benefit
Change in allocation reduces amount
available to cover actual orthodontic
services
> Patient incurs greater out-of-pocket expense
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2012 American Dental Association. All Rights Reserved
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CDT Code Errors – Prevention & Resolution
Prevention is the best practice –
> Address questions concerning proper coding
as the claim is being prepared
> Quality review before submission
Otherwise, procedure code errors are
usually revealed when –
> The payer rejects a claim
> Or asks for additional information before
processing
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2012 American Dental Association. All Rights Reserved
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Code Errors – Prevention
First source of coding guidance is in office:
> Current CDT Manual, or Dental Coding Made
Simple, published by the ADA
> Dentist’s knowledge and experience
The second source is the ADA
> By telephone to the Member Service Center –
(800) 621-8099
> By email to dentalcode@ada.org
©©2012
2012 American Dental Association. All Rights Reserved
36
Code Errors – Resolution
Review returned or denied claims to ensure
that the procedure codes are correct
If there is a coding error, prepare and
submit a corrected claim
> Errors should always be corrected, but may not
always eliminate an accusation of fraud
When there is no coding error, prepare an
appeal if there are grounds to do so
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2012 American Dental Association. All Rights Reserved
37
Code Errors – Payer error to appeal / 1
Patient is age 13 with predominantly adult
dentition and you report D1110
Payer says report D1120 for reimbursement
because the benefit plan says an adult is
age 15 or more
> Payer ignoring the D1110 descriptor and
asking you to report the wrong procedure code
> Coding for what you do is the only proper
action, regardless of payer policies or
reimbursement
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2012 American Dental Association. All Rights Reserved
38
Code Errors – Payer error to appeal / 2
D0120, D1120 and D1208 on a claim, but
payer says these are not separate – D0120
includes D1120 and D1208
Payer ignoring nomenclatures & descriptors
of 3 discrete codes, and redefining
procedure code D0120
> The payer may also be bundling
– Payers may benefit procedures in combination with
others as part of their payment policies
– But they should not claim that discrete procedures
are actually part of©©others
2012
2012 American Dental Association. All Rights Reserved
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©©2012
2012 American Dental Association. All Rights Reserved
40
Common Claim Denials
Dental claims can be denied, delayed or
alternate benefited for a myriad of reasons
Certain procedures tend to have a higher
frequency for denial and/or requests for
additional information
> D4341 Periodontal Scaling & Root Planing
> D4910 Periodontal Maintenance
> D2950 Core Buildup, Including any Pins
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2012 American Dental Association. All Rights Reserved
41
Denials – D4341 SRP
Dentists may not understand what appears
to be inconsistent SRP claim adjudication
For example, two patients have greater than
4mm pocket depth –
> One patient’s claim is paid
> The other patient’s claim is denied
Why the difference?
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2012 American Dental Association. All Rights Reserved
42
Denials – D4341 SRP
Payer claim processing policies vary
> One may require at least 4mm pocket depth
> Another may have different depth criteria
Patients may think denial means the dentist
is performing unnecessary work
> Denial does not mean that the SRP was not
necessary
> It only means that the clinical condition did not
meet the plan’s specific payment guidelines
©©2012
2012 American Dental Association. All Rights Reserved
43
Denials – D4910 Periodontal Maintenance
Claim denials occur because carriers have
limited benefits for this procedure, some –
> Reimburse this procedure only if it is delivered
within 2 to 12 months of SRP
> Deny benefits unless two or more quadrants
have received prior therapy
There are no such limitations in the CDT
Code
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2012 American Dental Association. All Rights Reserved
44
Denials – D4910 Periodontal Maintenance
As dentists you
> Must code for what you do, not to maximize
reimbursement
> Educate your patients that all procedures may
not be covered by some plans
– If known, tell patients in advance that plan provisions
may not provide for reimbursement of D4910 for
extended periods of time
©©2012
2012 American Dental Association. All Rights Reserved
45
Denials – D2950 Core Buildup
Certain carriers do not reimburse this
procedure
> The core buildup is bundled with a crown
procedure
> The payer’s action reduces the total
reimbursement amount
Dentists must help patients understand the
clinical basis for treatment
> Helps avoid post-treatment patient complaints
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2012 American Dental Association. All Rights Reserved
46
Your ADA can help
Contact CDBP Dental Benefit Information
Service staff for help with third-party payer
problems, questions and concerns
> By telephone: 800-621-8099
> Online third-party payer complaint form at
http://www.ada.org/ada/dentprac/default.aspx
©©2012
2012 American Dental Association. All Rights Reserved
47
Resolving 3rd party issues
A carrier was denying first diagnostic
radiographs for endodontic treatment done
on the same date of service as endodontic
therapy. These should have been paid but
were rejected by the claims auto
adjudication system. After contacting the
carrier and expressing our concerns, the
carrier resolved the issue.
©©2012
2012 American Dental Association. All Rights Reserved
48
Resolving 3rd party issues
A carrier denied a claim for a member
dentist who submitted a D2335 LI. The
nomenclature states D2335 resin-based
composite 4 or more surfaces or involving
incisal angle. The doctor was told twice by
the carrier that he needed to resubmit this
claim as a D2331 resin-based composite
two surfaces. After contacting the carrier
and expressing our concerns, the carrier
resolved the issue.
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2012 American Dental Association. All Rights Reserved
49
Resolving 3rd party issues
An EOB from a carrier stated that a, “D4211
is mutually exclusive to procedure D2752”
and it also stated that, “this is consistent
with the ADA general coding guidelines”.
We contacted the administrator to advise
them of our concerns with this language.
The administrator researched this and
decided to delete the references to the
American Dental Association.
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2012 American Dental Association. All Rights Reserved
50
ADA member benefit
Lessons of Contract Analysis
> The ADA continues to provide a free service to
members with contract analysis, if an unsigned
contract is sent through their constituent dental
society
> Now the ADA is developing a tool to assist
member dentists in analyzing the financial
impact of signing participating provider
agreements and how it may affect a dental
practice
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2012 American Dental Association. All Rights Reserved
51
Questions / Comments?
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2012 American Dental Association. All Rights Reserved
52