Re: [ACEsthetics] Insurance puzzle - your guidance and experiences..on biling combination or large cases to dental insurance

It used to be the case that Delta and many other insurances did not cover Full Mouth Restoration.  They considered 8 crowns within a 3 year period of time a full mouth and could demand money back from a contracted office retrospectively.

Maybe that solves Arun's problem just bill it out and find out it is not covered by insurance.

Dave

David Hamel DDS

1200 Broadway

Marysville, KS 66508

785-562-5529 O

785-562-8115 C

KDA Past President 2010

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On Jul 30, 2013, at 7:38 AM, Chris Hill <chrishilldmd@gmail.com> wrote:

David,

I agree, if you are not contracted, then there is no question.  Arun originally had stated that the associate was having trouble with Delta fees which he is a provider for (I think).  That's all I was speaking of.

Chris

On Tue, Jul 30, 2013 at 5:28 AM, David R. Boag DDS <spikedds@gmail.com> wrote:

On Jul 29, 2013, at 7:33 PM, Chris Hill <chrishilldmd@gmail.com> wrote:

I would question the legality of that, David.  That's one of those times that you say to yourself, "Self, if I was ever in court with regards to this case (be it the patient or the insurance company)  how much would I be sweating this?"  The lawyer in this case would be smiling and it most likely would not be yours.

Look, unless you are bound by contract, you can charge whatever you want to for your services. You have the right to charge $1,000,000 per crown if you like. It may be difficult to find too many takers, but the principle still applies. You are not legally bound. So long as you have a treatment plan signed by the patient, and they have signed informed consent, you have met your legal obligations provided you are not negligent or incompetent in your care.

Now in the case of a signed insurance contract, that is totally different. Break that, and THEN the attorney is smiling, cuz he's gotcha! You've got a lot more reason to sweat here, because the INSCO and their attorney's might be very interested in what you are doing, and they have a lot more $ to spend on attorneys than your patient does. You'll be sweating as the attorney makes you read the applicable paragraph that you, yourself, signed under no duress. 

The nice thing about tooth whitening is that so far, I've NOT ONCE seen it covered by inscos, so it's a safe code to do this, especially in states where laws have been passed prohibiting inscos from limiting fees on non-covered procedures. My example was not to limit this to JUST that procedure--but technically it COULD be done with just that procedure. It is much better to do it over several non-covered procedures.

I would rather see lab upgrades,

Very often breaks contracts

999 codes,

Depending on how they are used, can break contracts. Usually require a narrative description and if you use one, you'd better actually DO what the narrative says and it better not be something covered by or bundled with another code.

interims,temps,

Most insurance contracts BUNDLE these with final restorations, so in many cases if you separate them out, you are breaking contract. However, if you have the patient in temps longer than 6 months, that code CAN be used, and sometimes is NOT covered by the insco, so this code would work fine in that case, and instead of having one HUGE charge you can divide the difference out amongst the units. Fair game. My example was to show the principle at work--keep it legal, don't breach contract, and charge a fair fee, but this certainly makes things look less outrageous, IF they are not covered.

Be VERY careful using these codes as you are suggesting, though. Many times these ARE covered procedures (and will have a fee limitation), and oftentimes, they will pay on one or the other (the temps OR the final), and if they deem the temp charge "not indicated"--just like ANY procedure which they deem is not indicated--you can, by contract, have the entire fee for either of those procedures legally owed back to the patient/insco. 

Common example: You do S/RP on a contracted patient. They don't follow up with their recalls. They show back up 18 months after S/RP wanting their teeth cleaned, and they look like a train wreck again. The appropriate charge is for S/RP again. However, the insco likely has a two-year limitation on S/RP. You do it more than that, they deem this "overtreatment," and will require you to legally refund any monies collected for this procedure to the patient and to their company. They can do the same thing with any covered procedure so long as they can somehow justify an alternative. In this case, perio maintenance would be what they would say you can charge instead of S/RP. So you either do the entire case at a PM fee, or you can actually do a PM and NOT do the proper care, or you can refer the patient for perio sx. I have had this exact thing happen to me. Fortunately in my case, my patient actually went after the insco HARD, and got them to OK the S/RP, but I would never have been able to recover those fees without the patient's help. Never.

The same principle applies to doing crowns. If you do one on a tooth, and they don't see a reason (in their eyes) for the crown to be done, they will reduce the restoration to a direct amalgam, and you are stuck returning the difference to the patient & insco if collected.

When you use codes which ARE covered by the insco, you open yourself up to much more potential legal hassle. Try to stick with ones that are NOT covered. They are safer. Above all, have your attorney review your contracts before doing this. There may be precedent in your state for how these can or cannot be used. Again, some states have passed laws prohibiting inscos from limiting fees on non-covered procedures, and some have not. Check your state laws--or better yet pay a pro to do it.

diagnostics, etc.

Depending on the diagnostic, some are covered and some are not. Same principle as my above paragraph. If they are not covered by the policy, use those codes as well and divide the difference out amongst the many. For example, diagnostic casts are usually covered procedures. Often, so are orthotics. I'm not ,however, aware of a procedure code for use of a J7, although I am not well-versed at all on this diagnostic modality, but you could try that one if one doesn't exist. That could be one of the 999 codes that are not covered that could be justifiable.

And I would let your patient know that you are not submitting these things to insurance as they will not cover them anyways.  Their insurance will most likely be eaten up after 2 crowns anyways.

And depending on your insurance contract, in many cases you are both BOUND to submit to insurance, or at least legally bound to hold to the insurance fee schedule for covered PROCEDURES even AFTER their annual benefits have been used. This is NOT true in all cases. Gotta review your insurance contract(s). And if it happens to be one where this is NOT true, you are set. You would then charge the insco fee for the first 2 crowns and then the elevated fees for the rest once benefits are exhausted. If it is true, you can't do what you are suggesting here without breaching contract.

The bottom line of my post is that if ALL of the procedures you are doing are covered procedures, and if the contract to the insco binds you to the allowable fee schedule even after annual benefits have expired, you are stuck, so you've got to find at least one procedure that is not covered and divvy up the remaining reasonable case fee amongst those charges to justify what you are doing while keeping within the bounds of your contract. This assumes you are in a state where inscos are prohibited from limiting fees on non-covered procedures. If not, tread VEEERY carefully. Quite honestly, I think you'd be a fool to do this yourself without legal counsel guiding you. CERTAINLY don't do what I'm suggesting wi  based upon my advice alone. I'm not an attorney, and certainly not one in your state.

Be smart.

Ultimately, all this gobbledygook makes what Mac posted even more persuasive (not participating), but until a practice has enough cash flow, often contracting is a good idea. But then you'd better be a student of the game if you want to continue to do excellent dentistry like this within the bounds of insurance contracts.

David R. Boag, DDS

--
Chris Hill D.M.D.
www.CitySmilesStLouis.com

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