Dealing with negative EOBs

Oct. 1, 2000
A recent letter to the editor of Dental Economics highlighted a problem that many dental offices face every day. The letter-writer had just received a response from an insurance carrier for a predetermination of benefits for his patient. According to this dentist, the response was worded as follows: "Based on the information reviewed by our dental consultants, the prognosis for this service appears very uncertain. Therefore, no benefits can be allowed."

Carol Tekavec, RDH

A recent letter to the editor of Dental Economics highlighted a problem that many dental offices face every day. The letter-writer had just received a response from an insurance carrier for a predetermination of benefits for his patient. According to this dentist, the response was worded as follows: "Based on the information reviewed by our dental consultants, the prognosis for this service appears very uncertain. Therefore, no benefits can be allowed."

While most dentists and staff who work with insurance carriers on their patients` behalf are familiar with denials of treatment based on many types of criteria, this statement goes beyond what most astute carriers would consider proper. Despite the common, negative opinion about dental insurers, most carriers and their dental consultants restrict their involvement in a patient`s dental treatment simply to interpreting a particular dental contract. Second-guessing a doctor`s treatment or disallowing a benefit based on a consultant`s interpretation of a possible prognosis is becoming less and less acceptable.

Explanation of Benefit (EOB) language - while often inflammatory to dentists - usually follows carefully set-up guidelines to avoid legal problems. How much better it would have been for this particular carrier to provide the type of treatment-neutral statement that most companies have adopted. For example: "Based on contract parameters, no benefits can be allowed." Alienating patients who are the employees of the company that contracted their services usually does not help to get a carrier`s contract renewed. Insurance denials should be (but may not be) written in a nonconfrontational format, rather than in a "take that ... and what are you going to do about it?" manner.

The dentist`s letter to Dental Economics revisits a long-standing problem dentists have had with the language used in a patient`s Estimate of Benefits form. Negative EOBs create distrust. While positive changes have been made in recent years, negative statements continue to hurt the dentist/patient relationship. Negative statements range from the previously mentioned one to the more common: "The charge for treatment exceeds the usual and customary amount for your area." (This statement implies that the dentist is charging the patient an excessive amount for treatment.)

What can individual dentists and their staffs do about a negative EOB? As might be expected, the best defense is a good offense. Always anticipate the possibility of a negative Estimate of Benefits when dealing with insurance carriers. A patient can be alerted during the pretreatment conference to expect a negative EOB. Dentist and staff can explain that carriers are not in the business of taking care of dental patients; they are in the business of administrating and/or paying claims on behalf of the patient`s employer. The fact that a patient needs a particular procedure doesn`t matter to the insurance carrier. If treatment is not covered by the contract, a denial of service and a negative EOB is to be expected.

The treatment conference is the time to help patients understand and want recommended treatment, regardless of what their insurance may or may not pay. Dentists might approach dental costs in much the same way retailers of higher-end products and services do. As the popular hair-coloring commercial states, "It may be expensive, but I`m worth it!"

Dental treatment may seem a costly investment to many, but the patient definitely is worth it ... and should be told so! Attempting to deal with a patient`s perception of a negative EOB after the fact is difficult damage control. It is far better to have the patient on your side from the outset. If it turns out that a negative EOB never materializes, great! If it does, the dentist, staff, and - most importantly - the patient, are fully prepared.

Carol Tekavec, RDH, is the author of a new insurance-coding manual, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or visit her Web site at www.steppingstonetosuccess.com.

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