Diary of a claims adjuster

Before I took the job of chief dental consultant at Sun Life of Canada, I practiced dentistry for 29 years. I understand how frustrating dentistry can be. In this article, I will share with you some examples of the faulty claims I have had to review and a few ways in which you can improve your chances of avoiding misrepresentation. These pointers should help you in expediting the claim`s process.

Paul Bornstein, DMD

Before I took the job of chief dental consultant at Sun Life of Canada, I practiced dentistry for 29 years. I understand how frustrating dentistry can be. In this article, I will share with you some examples of the faulty claims I have had to review and a few ways in which you can improve your chances of avoiding misrepresentation. These pointers should help you in expediting the claim`s process.

Wednesday morning, 8:15 a.m.

Ridiculous Claim No. 1: Four quadrants of scaling and curettage. All six measurements for all 32 teeth were four millimeters.

Time for two aspirins!

Ridiculous Claim No. 2: A crown, the envelope please ... no X-ray.

Red pen ... stamp ... goodbye.

Ridiculous Claim No. 3: A bridge, the envelope please ... 22 unmounted X-rays scatter across the floor! Pick them up (It`s still early in the day, and I`ve been to Minnesota before. It`s nice.). I`ll search for the right one this time. But, I`ll be sure to remember this dentist`s name!

Ridiculous Claim No. 4: Another crown ... the X-ray ... wrong side? Who sent this one?

Red pen ... stamp ... next!

Ridiculous Claim No. 5: A new crown, X-ray ... the crown already is in place? Call the office. "Hello, quick question. Is this the correct patient X-ray? It is. Well, there`s already a crown in place and the claim form states initial placement."

"Our computer only can print `yes` in that box," the office manager replied.

So, I told her it was fraud ... and she said there was nothing she could do about it.

Claim denied ... where`s that blacklist?

Ridiculous Claim No. 6: Six-thousand-dollar bridge ... X-ray envelope is empty. "Hello. Yes, you`ve mailed us a claim with no X-ray. Oh, you don`t send X-rays. You don`t take them? Unless it`s necessary?"

Two more aspirins, claim denied, red pen, stamp, flag ... lunchtime!

Have you ever been "flagged" by a dental-insurance company? Would you be surprised to find out that even if you had been "flagged," you wouldn`t know it?

During my three years as chief dental consultant, I saw claims like those mentioned above each and every day. Time after time, I would scratch my head and ask myself if the average dentist has any idea how important it is to submit a claim form properly.

How can the owner of a large practice possibly remain vigilant over each and every claim filed? With so many different contracts in force, how should a dentist go about guarding himself against submitting suspicious claims?

You have the claim form right in front of you. Each form has 42 questions. Every question must be answered. Who do you think reads the claims at the insurance company? Nine times out of 10, it`s not a dentist or even a hygienist - it`s an entry-level employee or perhaps even a temp.

Claims that come in vague, unclear, suspicious, or incorrect do not go through some editing process by a qualified dentist before they arrive on the desk of the claim`s reviewer. Blank spaces will not be filled in, and conjecture is not an option. The temp will read the claim, compare it to the correct models, and make a decision ... and the reviewer will do it quickly because he or she has another 299 claims to process.

Hint: Make everyone`s job easier. It is a good idea to write the doctor`s name and address and the patient`s name, Social Security number, and insurance group number on each X-ray envelope. All X-rays must be recent.

I have sat with my head in my hands on many a Monday morning, staring at 15-year-old X-rays (don`t laugh!) and wondering what the temperature is in Barbados and if 24 hours is enough advance notice to reserve a seat!

Secondly, developing film is a necessary skill that many offices never adequately learn. For example, an X-ray arrives in a dated envelope with a perfectly completed form. But, it looks more like a bunch of storm clouds - photographed through a windshield at 70 miles an hour - than a set of teeth. That claim will be denied.

All X-rays need to be clear enough that the claim`s reviewer can adequately assess the validity of the claim.

Wednesday afternoon, 2:20 p.m.

Ridiculous Claim No. 7: A crown, tooth No. 20, X-ray included ... looks like a deciduous tooth. Called the doctor. "Yes," he said, "it`s a deciduous tooth."

"Then why did you call it tooth No. 20 when, in fact, it`s tooth K?" I asked.

"Well, the patient isn`t going to get tooth 20, and K`s roots are in good shape and should last," the dentist replied.

"But the contract specifically excludes crowning deciduous teeth; do you know you`re committing fraud?" I asked.

"Well, I guess I am," the doctor said, "but I`m just trying to do the patient a favor."

Bad idea ... claim denied ... doctor blacklisted.

Ridiculous Claim No. 8: $1,800 bill for an apicoectomy, separated into different codes - i.e., Code 03425, apicoectomy; Code 03426, apicoectomy w/additional root; Code 03430, retrograde filling; Code 04260, osseous surgery; Code 04263, bone replacement; Code 07285, biopsy of oral tissue - hard.

My findings - Creativity: A+; Aggravation: F for fraud, failure, and fruitcake. Claim denied. What are the odds that this dentist charged his patient $1,800?!

Tee time

"I don`t know," office managers would tell me almost every single day. "The doctor never looks at the claims or the X-rays that go out."

I imagine, for whatever reason, dentists simply don`t know the importance of filing claims correctly or violating the laws that govern the process. Doctors! It`s your signature on the claim - the same signature that`s on your bills, your checkbook, and your license. If there is a problem with your claims - inadvertent or otherwise - it is your problem.

Am I trying to strike fear into your hearts? No. I would just like to see dentists appreciate this situation a little better, help them shake off a bit of unnecessary stress, and collect more money faster.

Again, you will be doing yourself a big favor if you do not leave a single question blank. I regularly saw claims with Question No. 14 (Is the patient covered by another plan?), No. 32 (Was the damage caused by an accident?), and No. 34 (Date of prior placement) left blank. Blank spaces look suspicious; one starts to think it`s a little too quiet around here.

If your office happens to be recognized by an insurance company as suspicious, every single claim you file from that point on - no matter how small - will be scrutinized intensely. You still may get paid for the claim, but payment will be delayed. Larger claims require more complex - and often quite subjective - decisions, which, in some cases, take into account how the insurance company "feels" about the dentist.

The bottom line? Be honest, be neat, and be thorough so everyone can play fairly.

Formerly the chief dental consultant for Sun Life Insurance of Canada, Dr. Paul Bornstein now offers in-office dental-insurance consulting with an emphasis on maximizing profit, stress management, and avoiding fraud. For more information, contact him at (802) 583-2702; fax him at (802) 583-1494; or e-mail him at paulborn@madriver.com.

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