Insurance merry-go-around

Feb. 1, 1999
As I thumbed through the November issue of Dental Economics, my eye caught the Viewpoint by Dr. Paul Bornstein. His review of ridiculous claims was mildly entertaining, but very troubling. As I read the article, I felt more and more as if Dr. Bornstein would group all dentists as white-collar criminals. I wonder if there is any practice that is not "flagged" for some reason or other.

Fred H. Drews, III, DDS

Hattiesburg, MS

As I thumbed through the November issue of Dental Economics, my eye caught the Viewpoint by Dr. Paul Bornstein. His review of ridiculous claims was mildly entertaining, but very troubling. As I read the article, I felt more and more as if Dr. Bornstein would group all dentists as white-collar criminals. I wonder if there is any practice that is not "flagged" for some reason or other.

His comment that "Nine times out of 10...it`s an entry-level employee or perhaps even a temp" who first reviews the claim is very enlightening. This explains why so many claims are returned asking for information that clearly is printed on the claim form.

His remarks about X-rays also hit home. I remember the days before we started filing electronically. We would staple the complete series of X-rays to the paper claim and insurance companies could not keep up with them. Many clearing houses are not capable of handling electronically submitted radiographs. So, now we have an electronic claim followed by an X-ray in the mail and the insurance company is going to match them up? Right!

We recently submitted a pretreatment for the patient to provide a three-unit fixed bridge. The patient had both primary and secondary insurer. The primary responded in a timely manner and indicated coverage. We then attached a copy of the primary coverage to the secondary pretreatment and mailed that with appropriate mounted radiographs. The secondary denied the claim for the pontic. My office manager called the secondary insurer for clarification. The reason given was that it was a pre-existing condition. When asked, the insurance claims representative admitted that the patient was insured (this was 1994). The representative then said that the claim was denied because the code submitted for the procedure (7250 surgical removal of residual root) indicated that the tooth was not functional and they would not cover replacement of nonfunctional teeth.

When informed that the residual root was removed because the crown fractured, this most helpful representative agreed to review the claim if we submitted an X-ray showing the intact tooth. Imagine submitting a four-year-old X-ray. Why didn`t we think to do that in the first place? Shame on us!

The number-one problem with insurance claims is that both the insured and the dentist often lose sight of the fact that insurance companies are not in the business of paying claims. Their business is collection of premiums and providing stockholders with dividends and incidentally creating huge compensation packages for the bean counters holding the top administrative positions.

Will I be "flagged" for this letter? Am I already on a blacklist because I question results and offer assistance to my patients to maximize their benefits? I know that I do not participate in fraudulent claims, but I readily admit that I do not review all claims as Dr. Bornstein suggests. I do know that an entry-level or temporary employee does not prepare my claims. I also know that a copy of Dr. Bornstein`s article and his response is on the way to my state insurance commissioner`s office.

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