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Submitting to the Medical Plan — It’s Not About Hiding the Truth!

Dental Insurance Today — Jan 2017

dishonest expertsIn my previous post, The Basics of Myth-Busting Practice Management, I introduced one of my favorite workshop subjects. I could speak for days on the reality and practical application of real-world practice management. After being in the industry —  as well as representing all four sides of it — for over 30 years, I can honestly say that I have seen quite a few “flash in the pan” trends come and go.

On that same note, the lies and fallacies being taught by so-called “experts out standing in the field” continue to confuse and mislead those who unknowingly accept them as truth but are nothing more than smoke and mirrors.

Let’s begin to solve the ethical issue of medical/dental cross coding by simply introducing the challenge as it most often presents itself to the administrative team.

Extractions, as well as all the other codes in the D7000 section of the sequence, are the more common dental procedures often paid out with (subrogated) benefits of the patient’s health plan. No matter the patient’s age, health status or type of necessary extrication, the patient’s dental plan will most often want to first determine any additional coverages from medical prior to them considering any portion of reimbursable liability. This will also curtail the so-called “double dipping” that occurs when unscrupulous offices, as well as patients, fraudulently bill and collect from multiple plans for the same dated service.


First Things First…

Submit the dental claim to the dental payer making sure to specify any other coverage the patient has in effect on the date of service. If the patient is only covered under an additional dental plan, provide the specific responses to questions #4 to #10 on the © 2012 ADA Claim Form. The same would hold true if the patient is only covered by an additional medical plan. If you are dealing with both an additional dental and medical plan, the dental information goes again to questions #4 to #10 while the medical is specified in #11.

It is imperative that the initial claim to the dental plan be accurate as well as truthful. To intentionally neglect specifying the inclusion as well as addition of disclosed additional coverages is a fraudulent practice. All plans must be disclosed on the initial as well as subsequent claim filings.


Now and Forever Always Follow the EOB

If and when the initial claim is accurate as well as complete, the adjudication will be complete and the claim will be closed. The EOB (explanation of benefits) will specify who is to, and did, pay toward the open financial liability. Now one of three instances will occur. They are:

  • If it’s paid and you are done, evaluate and collect patient balance.
  • If it’s not paid as (excluded, non-covered, etc.), evaluate and collect patient balance.
  • If it’s not paid PENDING medical or another/other plans decision, send it to medical as follows…

If it’s not in print directly from the plan it does not exist.

At this point your key to success is the printed statement from the dental plan whereby they want confirmation of the other/medical plans acknowledgment or declination of coverage.

Send a copy of the declination notification from dental plan to the medical plan with the following attachments:

  • A 1500 Health Insurance Claim Form but only complete questions #1 to #13 as well as #25 to #33. These are the questions specifying plan / insured / patient, etc. as well as treatment location and billing provider.
  • For the middle section of the 1500 Health Insurance Claim Form addressing questions #14 to #24, simply X it out and print “SEE ATTACHED.” And what is attached…
  • A completed dental claim form appropriately addressed and specified according to the other plan. Group number, policy number, relationship to insured, etc.
  • The treatment on the dental claim form is coded using the appropriate dental procedure code numbers.
  • Always helpful is to also include a copy of your clinical documentation from the dates of service.

Bundle up all these goodies in the following order from top to bottom:

  1. 1500 Health Insurance Claim Form (#’s 1-13 and 25-33 only)
  2. Copy of declination notification from the dental plan
  3. Completed dental claim form with dental code numbers
  4. Copy of treatment notes

The medical plan now has all the information needed to determine appropriateness of coverage based on their parameters of payment. If the treatment rendered is part of their coverage, the adjudication process will take place. If and when the medical plan determines this to be a dental procedure the dental plan is already set to process the claim. It’s just that simple.

Now here is where it has the potential to get dirty. The patient gets the short end of the stick when and if the medical plan says it’s their reimbursement liability but the patient has a huge deductible needing to be met. With that situation the dental plan often won’t pay, as it is not their liability, its medicals, leaving the patient with a huge out of pocket expense.

The world of reimbursement is continually changing. Ask your referring oral surgeons what they are doing and you will find out that they are most often opting out from the medical network so as to not be financially penalized, as are their physician counterparts. Also, be careful and aware of the payers who are automatically opting in dentists to be part of their medical networks. Look at what has already happened with the so-called mandatory Medicare Advantage (C and D) opt-in, opt-out confusion with dentists. Ever wonder why the feds pushed back, again, the compliance dates to now be 2019?

In conclusion, medical coding of dental procedures has little or nothing to do with legally and ethically securing benefits on behalf of the patient through their medical plan.

What do you think?

Tom Limoli

Tom Limoli

“The Nation’s Leading Reimbursement Expert”

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