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Dealing
with insurance carriers creates many problems for dental offices.
Problems with Explanation or Estimate of Benefits (EOB), post-payment
utilization review, and payment delays are only a few of the issues
offices deal with on a daily basis. What follows are answers
to some common questions and simple answers.
The
following are some of the PPOs that we accept at our office:
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 Why do some insurance
rules go against proper dental procedures and services?
 Most insurance
carriers employ attorneys who help set up the plans. Remember, plan
parameters, or "rules" are designed to sell plans and/or
make money, not fully fund the most appropriate treatment.
Why do carriers
deny a claim?
Carriers deny
claims based on the parameters of a patient's contract. If a service
is not covered in the contract, it will not be a benefit, regardless
of dental or medical need and regardless of its format.
What can I tell
patients who tell me that their plans cover exams and certain other
procedures at 100 percent?
The "100
percent," as defined by the insurance carrier, is actually
just what the insurance carrier "allows" as its 100 percent
or full payment toward a procedure. It bears no relationship to
what our office may actually charge. For example, our office may
charge $80 for an exam. The insurance carrier may allow $60 as its
100 percent payment for that examination, leaving $20 for the patient
to pay.
Why do carriers
stall 30-60 days or more on claim payment?
Turn-around times
on claims are slow. It is to the insurance company's benefit to
release the payment as late as possible.
How do carriers
come up with "usual and customary" fees?
Insurance plans
typically base their fees on one of two systems: "charging
patterns' or "relative-value scales." Charging patterns
usually are based on a data pool of charges for each section of
the country. Relative-value scales are based on studies of what
goes into each type of dental procedure. The exact method used by
each insurance carrier and the actual fees and "percentiles"
set for each plan are considered to be trade secrets and are not
revealed to patients or dentists.
An insurance carrier presents several percentile levels and related
premium payment amounts to employers buying the plans. Whatever
plan is selected by the employer becomes the set fee schedule or
"UCR" fee schedule for that plan. The term "UCR"
might more accurately be called a "negotiated fee." UCR
is simply what is considered the accepted fee for each particular
plan, as negotiated between the employer purchasing the plan and
the insurance carrier providing the plan.
Can patients obtain
a list of codes and a carrier's allowed benefits for each code?
Theoretically,
this should be allowed under federal labor law for plans covered
by ERISA. (ERISA stands for the Employment Income Security Act of
1974, which was put in place to protect employee pensions and company
self-funded plans from "excessive" state regulation.)
In fact, in 1996, a federal Labor Department "advisory opinion"
stated that "usual and customary" fee schedules used to
determine insurance benefits for companies falling under the ERISA
Act are "instruments under which the plans are established
or operated" and must be given to participants of the plans
when requested in writing. However, few, if any, patients have ever
obtained this information. Carriers regard the allowed amounts as
trade secrets and will not reveal them.
Can offices obtain
the allowed amounts and inform patients?
No. It is possible
to purchase a general-fee profile, known as the Prevailing Healthcare
Charges System. It is commonly used by carriers to determine fees
by code for each zip code area in the country. This fee profile
system is extremely expensive and the information is not specific
for each plan.
Why do carriers
refuse payment for panographs and other X-rays when taken the same
day?
More than 10 years
ago, many carriers eliminated payment for a full-mouth series of
radiographs and a panograph when taken on the same day - or even
within the same three year period. (Most carriers consider seven
periapicals as a full-mouth series, despite the fact that most dental
personnel consider this to be 14-18 films.) Some carriers now are
eliminating payment for any PA's taken on the same date as a panograph.
How can an office
file a complaint with the insurance commissioner?
State insurance
commissioners are given the task of protecting the consumer, not
the dentist. However, if a certain company has many complaints,
it might affect their ability to continue business in a state. A
patient letter, email, or a letter from an employer usually pulls
more weight.
Most state insurance commissioners have Web sites for obtaining
addresses, phone numbers, and email addresses.
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