Carol Tekavec, RDH
The ADA Current Dental Terminology provides numerous treatment codes requiring the inclusion of an explanation or "report" when filing claims for patients. In addition, many ADA codes provide a definition that is not considered complete by insurance carriers without supplemental documentation and attachments to the claim. Insurance company requests for periodontal charting and radiographs to substantiate treatment are common. Most dentists and staff wonder what purpose all of this documentation serves, other than to delay the payment of benefits to patients or their employers.
To understand these documentation requirements, let`s review some basic facts regarding traditional dental insurance. Usually, insurance companies are contracted by employers to set up benefit plans for their employees. Often, several companies are asked to submit sample plans focusing on three parameters: premium costs to the employer (and sometimes the employees as well), benefits offered, and scale of fees. Insurance-fee profiles typically are based on the carrier`s individual computer compilation of fees for a particular zip code or reports from the Health Insurance Association of America.
Based on this information, the employer selects an insurance company and signs a contract for a given period of time. While various factors are considered, the insurance premium, or cost to the employer, usually is the deciding element.
The insurance company provides the employer with plan administration and claims payment. The employer also relies on the insurance carrier to make sure that the company is getting its money`s worth and that employees (patients) and dentists are not taking unfair advantage of the program. This is particularly important to employers with administrative services only (ASO) insurance contracts. The employer is not only paying premiums, but is at financial risk for claims.
While insurance carriers are not particularly beloved by employers, a perception of dentists and employees needing to be watched is inexplicably persistent. A national meeting for insurance consultants recently featured a seminar presented by two vice presidents of human resources from two different Fortune 500 companies. When asked why Direct Reimbursement was not a favored benefit plan for their companies, both speakers were nonplussed. "Who would watch the dentists?" they wondered.
Insurance consultants for traditional insurance plans function as interpreters of the details for each plan contract. Employers require that these consultants pay only covered contract procedures submitted with supporting documentation.
Any dentist who has been frustrated by a lack of coverage for a patient`s claim can point to the limited nature of many current plan contracts. If a patient`s condition does not fit a particular category or fall within certain specifications, no benefit applies. For example many plans specify that, for a 04341-Periodontal Scaling and Root Planing-per Quadrant to be a benefit, the patient must demonstrate at least 5mm pockets in each quadrant to be scaled. Radiographs and periodontal charting must be provided for claims to be considered and paid.
The American Academy of Periodontology states in their policy statement regarding "Third Party Requests for Records" in May 1999 that "routine requests for records are inappropriate and add to the cost of dental care." However, the Academy does support cooperation with occasional requests for charts and radiographs to resolve "specific questions." Regardless of philosophy, without assistance from dentists and their staffs, most patients would be unable to provide the necessary documentation their insurance requires. Documentation is a fact of life for many dental offices because even patients who can afford dental treatment without insurance benefits want their insurance to pay.
Attachments and other documentation submitted with a patient`s initial claim, rather than after being requested, can help speed payment.
Carol Tekavec, RDH, is the author of two insurance-coding manuals, co-designer of a dental chart, and a national lecturer with the ADA Seminar Series. Contact her at (800) 548-2164 or at www.steppingstonetosuccess.com.