We have all been there. Mr. Jones comes in for his regularly scheduled hygiene appointment and periodic examination. Your hygienist reminds you there is a “watch” on tooth number 3 (#3). For years you have been monitoring tooth #3. There is a sizable MO (mesial-occlusal) amalgam with multiple crack lines surrounding the cavosurface margins. Your explorer catches when run over the lines, indicating separation of the tooth structure. The radiograph indicates a large restoration, one that should be replaced as there is concern of marginal leakage. The replacement restoration is now anticipated to encompass more of the mesial-buccal and mesial-palatal cusps. This tooth takes the majority of the posterior chewing forces. There is evidence of generalized wear and attrition from years of Bruxism. Your professional recommendation is to remove the existing alloy restoration and place a core-buildup followed by an indirect restoration, an all-ceramic crown. Mr. Jones is completely understanding of the need for the proposed treatment and is interested in scheduling ASAP to prevent his oral condition from worsening (the treatment recommendation conversation is another topic of interest we can discuss). Treatment is completed, the final crown is seated, financial arrangements were made for the patient portion to be collected and a claim submitted to the patient’s insurance carrier for reimbursement to the office; benefits being reassigned to you as the provider for the treatment rendered.
However, nearly two months after completion of the case, despite the obvious nature of Mr. Jones’ restorative needs on tooth #3, your office received the explanation of benefits (EOB) from Mr. Jones’ insurance provider and its adverse determination, detailing the claim was denied for “not meeting medical necessity.” Mr. Jones is not happy that he owes your office approximately double what was expected. You are in the tough position of pushing for the collections of the amount remaining from the treatment completed, or to adjust the account with a professional courtesy “write-off” making the patient ultimately happy, leaving you giving away patient treatment for far less than it’s worth. Neither option is ideal;
what do you do?
Fufidio Consulting Group (FCG) covers a wide variety of topics and offers a multitude of services to help you practice and bill smarter. FCG is here to help you be paid for the services you do and keep your patients and team members happy by reducing the burden of unpaid insurance claims. FCG’s coaching by Dr. Fufidio will provide you with insight and education into what insurance Payers are evaluating when making benefit determinations. Dr. Fufidio will train you and your team on the common requirements for benefit reimbursement and how to best document your clinical findings to submit to the insurance carriers for reimbursement. Dr. Fufidio can set you up for a more predictable claim submission process allowing your team to make more educated submissions. Dr. Fufidio will coach you on recommended means of follow-up for your claims to be paid more appropriately, and will counsel you on explaining when a service truly is not covered by the Payer. Although she cannot tell you what to do to have your claims paid, that determination is made by the insurance company and in accordance with their clinical criteria requirements for benefit allocation, Dr. Fufidio can educate you and your team on the things most certainly NOT to do.
Schedule an introductory call to find out more about how we can best help YOU. Start building towards a better benefits success rate today!
FCG's Benefit Determinations versus Treatment Recommendations
Our summary guide to understanding the decision behind dental insurance claims review and start building towards a better benefits reimbursement rate.
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