Contracts, Coding and Claims

© 2012 American Dental Association. All Rights Reserved 1

Contracts, Coding and Claims

Montana Dental AssociationMay 2, 2013

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© 2012 American Dental Association. All Rights Reserved 3© 2012

To be addressed –

I. Non-Par Issues with Third-Party Carriers

II. Contract Issues

III. Payer Cost Containment Methods

IV. Preventing & Resolving Claim Errors

V. Common Claim Denials


Non-Par – Assignment of benefits

Patient’s signed request ignored – pay patient directly

> Carriers claim it is their prerogative to honor assignment

> It is a network provider “perk”

Problem for dental office – patient holds the money

> May not pay the bill sent by the office


Non-Par – More patient out-of-pocket

Greater patient out-of-pocket expense with non-par

> Higher deductible & lower annual maximum> Lesser per-procedure reimbursement amount

Non-par dentist at a distinct disadvantage> Patient’s potential higher out-of-pocket

expense

Intent is to steer patients to par dentist


Non-Par – Failure to receive EOB

Many carriers send EOBs only to patients and participating dentist offices

> Claim this is a benefit of being a par dentist

Causes problems for the non-par office – need EOB to:

> Assist patients with questions about reimbursement amount

> Address inappropriate messages


Non-Par – Faster payment for discounts

Goal – persuade dentist to accept lower amount for faster payment

> Action by intermediaries on behalf of the third-party payer

If contacted determine if the discount is –> A one-time arrangement > Continuing without additional consent

ADA’s contract analysis service can assist

© 2012 American Dental Association. All Rights Reserved© 2012 8




Contract – “All Affiliated Carriers” clauses

May be part of participating provider contract

If contract is signed the dentist becomes a participating provider of the –

> Third-party payer offering the contract> Any affiliate, even if not specifically named


Contract – National processing policies

Par dentist may have agreed to abide by payer's national processing policies

> Policies may not appear in the contract, only incorporated by reference

Policies may be posted on payer’s Web site> Describe how every dental procedure code is

adjudicated


Contract – Component / Denied procedures

Patient cannot be billed for procedures that the payer considers incidental to other procedures

When procedures are disallowed it means that the plan –

> Does not cover the procedure> May not allow the dentist to charge the patient

for the procedure


Contract – Provider Relations contacts

Problem resolution requires access to qualified payer staff

Dentist to dental consultant contact at professional level enables

> Rapid problem resolution> Timely claim adjudication and payment


Contract – Removal from network lists

After ending par-provider status change has not been made public (e.g., Internet)

Raises issues for patients and dentists> Appointments scheduled then cancelled when

patient learns dentist is no longer in network> Resolving patient objections to balance billing

or billing for services at dentist’s full fee




Cost Containment – aka “Managed Care”

Intended to reduce or eliminate a benefit plan’s financial exposure

Before patient receives care the benefit plan sponsor and payer should explain:

> All limitations, exclusions and other cost containment measures (e.g., in & out of network)

> Application of deductibles, co-payments, coinsurance and balance billing


Containment – Annual maximums

Total dollar amount available to fund a patient’s necessary dental care

> May only cover a portion of costs for necessary care

Dental plan reimbursement annual maximums commonly $1,000 to $1,500

> Higher annual maximums are rare

Annual maximums are said to be market driven


Containment – LEAT provisions

Least Expensive Alternative Treatment> Reduces benefits to the least expensive of

other treatment options determined by the benefit plan

> Dentist may recommend a fixed denture – but plan may allow reimbursement only for a removable partial denture

A pretreatment estimate may be helpful to prevent patient confusion


Containment – Bundling procedures

Systematic combining of distinct dental procedures that results in a reduced benefit for the patient/beneficiary

Radiographs are a common example> Panoramic image and bitewings may be

combined and recoded as a full mouth series (FMX)

> Future D0210 claim is then subject to benefit plan frequency limitations (e.g., 1 FMX every 5 years)


Containment – Downcoding

Payer changes procedure code on claim to a less complex or lower cost procedure

> May interfere with dentist-patient relationship unless EOB states it is only due to a business reason

Carriers typically do not disclose their downcoding, or bundling, policies during the contract negotiation process


Containment – Exclusions

Many dental plans do not provide coverage for all dental procedures

> This does not mean that the services are not necessary

Prepare a treatment plan based on the patient’s clinical needs

> Patient acceptance of a treatment plan is often influenced by available benefits


Containment – Plan frequency limitations

Some procedures covered only at stated intervals, commonly –

> Cleanings and examinations twice in a plan-year or once every six months

> Intraoral – complete series radiographs once every 5 years

> Bitewings once every 6 months> Crowns once every 5 years


Containment – Not dentally necessary

Clauses that state only medically or dentally necessary procedures are covered

> If claim denial does states services are inappropriate or not medically necessary – may be an ethical issue with the dental consultant

> Dental consultant does not have enough information to make a diagnosis

> Should limit denial language to not payable under the dental plan


Containment – Predetermination

Sometimes required when charges expected to exceed a certain dollar amount

Not a payment guarantee – dollars may be used for other services by another dentist before predetermined procedure delivered

Returned with the following information: > Patient’s eligibility and covered service > Deductible, co-pay and amount payable


Containment – Deductibles

Amount of a dental expense that is the patient’s responsibility

Due before a third-party payer assumes any liability for payment of benefits

May –> Be an annual or one-time charge> Vary in amount from program to program


Containment – Pre-existing conditions

Restriction on coverage for dental conditions present before an individual’s enrollment in the plan

> Some plans may never cover a pre-existing condition

> “Waiting period” of varying length before coverage is available


Containment – UCR

Misleading acronym for 3 different concepts> Used by a dental plan to describe its own fee

reimbursement schedule

No universally accepted method for determining the maximum plan benefit

> Each company creates its own – and can vary a great deal among plans in the same area

> Company’s maximum plan benefit may be lower than area dentists’ full fees for the same service


Containment – Payment reductions

At least three major carriers have reduced maximum allowable fees for participating providers

Provisions for unilateral reduction are in current and new contract forms

When notified of a reduction a dentist may negotiate fees on an individual basis

© 2012 American Dental Association. All Rights Reserved© 2012

Containment – Reclassify & Cost Shift

Reimbursement for extractions needed prior to orthodontic treatment

> Some carriers now allocate to the limited lifetime orthodontic benefit

Change in allocation reduces amount available to cover actual orthodontic services

> Patient incurs greater out-of-pocket expense

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CDT Code Errors – Prevention & Resolution

Prevention is the best practice –> Address questions concerning proper coding

as the claim is being prepared> Quality review before submission

Otherwise, procedure code errors are usually revealed when –

> The payer rejects a claim> Or asks for additional information before

processing


Code Errors – Prevention

First source of coding guidance is in office:> Current CDT Manual, or Dental Coding Made

Simple, published by the ADA> Dentist’s knowledge and experience

The second source is the ADA> By telephone to the Member Service Center –

(800) 621-8099> By email to [email protected]


Code Errors – Resolution

Review returned or denied claims to ensure that the procedure codes are correct

If there is a coding error, prepare and submit a corrected claim

> Errors should always be corrected, but may not always eliminate an accusation of fraud

When there is no coding error, prepare an appeal if there are grounds to do so


Code Errors – Payer error to appeal / 1

Patient is age 13 with predominantly adult dentition and you report D1110

Payer says report D1120 for reimbursement because the benefit plan says an adult is age 15 or more

> Payer ignoring the D1110 descriptor and asking you to report the wrong procedure code

> Coding for what you do is the only proper action, regardless of payer policies or reimbursement


Code Errors – Payer error to appeal / 2

D0120, D1120 and D1208 on a claim, but payer says these are not separate – D0120 includes D1120 and D1208

Payer ignoring nomenclatures & descriptors of 3 discrete codes, and redefining procedure code D0120

> The payer may also be bundling – Payers may benefit procedures in combination with

others as part of their payment policies– But they should not claim that discrete procedures

are actually part of others



Common Claim Denials

Dental claims can be denied, delayed or alternate benefited for a myriad of reasons

Certain procedures tend to have a higher frequency for denial and/or requests for additional information

> D4341 Periodontal Scaling & Root Planing> D4910 Periodontal Maintenance> D2950 Core Buildup, Including any Pins


Denials – D4341 SRP

Dentists may not understand what appears to be inconsistent SRP claim adjudication

For example, two patients have greater than 4mm pocket depth –

> One patient’s claim is paid> The other patient’s claim is denied

Why the difference?


Denials – D4341 SRP

Payer claim processing policies vary> One may require at least 4mm pocket depth> Another may have different depth criteria

Patients may think denial means the dentist is performing unnecessary work

> Denial does not mean that the SRP was not necessary

> It only means that the clinical condition did not meet the plan’s specific payment guidelines


Denials – D4910 Periodontal Maintenance

Claim denials occur because carriers have limited benefits for this procedure, some –

> Reimburse this procedure only if it is delivered within 2 to 12 months of SRP

> Deny benefits unless two or more quadrants have received prior therapy

There are no such limitations in the CDT Code


Denials – D4910 Periodontal Maintenance

As dentists you> Must code for what you do, not to maximize

reimbursement> Educate your patients that all procedures may

not be covered by some plans– If known, tell patients in advance that plan provisions

may not provide for reimbursement of D4910 for extended periods of time


Denials – D2950 Core Buildup

Certain carriers do not reimburse this procedure

> The core buildup is bundled with a crown procedure

> The payer’s action reduces the total reimbursement amount

Dentists must help patients understand the clinical basis for treatment

> Helps avoid post-treatment patient complaints


Your ADA can help

Contact CDBP Dental Benefit Information Service staff for help with third-party payer problems, questions and concerns

> By telephone: 800-621-8099> Online third-party payer complaint form at

http://www.ada.org/ada/dentprac/default.aspx




Resolving 3rd party issues

A carrier was denying first diagnostic radiographs for endodontic treatment done on the same date of service as endodontic therapy. These should have been paid but were rejected by the claims auto adjudication system. After contacting the carrier and expressing our concerns, the carrier resolved the issue.

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A carrier denied a claim for a member dentist who submitted a D2335 LI. The nomenclature states D2335 resin-based composite 4 or more surfaces or involving incisal angle. The doctor was told twice by the carrier that he needed to resubmit this claim as a D2331 resin-based composite two surfaces. After contacting the carrier and expressing our concerns, the carrier resolved the issue.

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An EOB from a carrier stated that a, “D4211 is mutually exclusive to procedure D2752” and it also stated that, “this is consistent with the ADA general coding guidelines”. We contacted the administrator to advise them of our concerns with this language. The administrator researched this and decided to delete the references to the American Dental Association.

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ADA member benefit

Lessons of Contract Analysis

> The ADA continues to provide a free service to members with contract analysis, if an unsigned contract is sent through their constituent dental society

> Now the ADA is developing a tool to assist member dentists in analyzing the financial impact of signing participating provider agreements and how it may affect a dental practice

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