…word letter to a dental benefits company’s faceless dental consultant trying to explain why you treated a patient’s tooth a certain way when that consultant denied coverage for the procedure because the need for your treatment wasn’t obvious on the X-ray which you sent with the claim…
There is no doubt that our treatment decisions are under greater scrutiny by dental benefits companies. That isn’t necessarily a bad thing. We all need to be accountable for the care we provide for our patients. However, when a dental consultant or claims reviewer who has never examined the patient denies the appropriateness of the treatment rendered, it can be very problematic for the dentist patient relationship.
Depending on the wording of the denial, the patient can be left with the impression that the treatment they received was excessive or just plain wrong. The treating dentist is left to try to explain that difference of opinion to the patient, and that dentist’s staff has to take time to reprocess the claim or write letters of appeal.
The recommendation from Erika Valadez, WDA dental practice and government relations associate, is to take photographs. Take a preoperative image. Take several images from different views especially if that fracture line or undermined cusp is not obvious on the X-ray. If something unexpected is found during the procedure, get a photo of that to document what you saw.
Today’s intraoral digital photography is completely different from when I learned with 35 mm film and juggling mirrors for reflections in to capture the subject. Fiber optics and LED lights have made the process so much easier. Taking those photos are something that your hygienist or assistant can do for you, and your front desk staff can easily email those images to support your claim.
Erika’s advice “Small changes and work on the front end are much easier than trying to fight for your reimbursements on the back end.”
