Contracts, Coding and Claims

2. Contracts, Coding and Claims Montana Dental Association May 2, 2013

3. To be addressed – • Non-Par Issues with Third-Party Carriers • Contract Issues • Payer Cost Containment Methods • Preventing & Resolving Claim Errors • Common Claim Denials

4. 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

5. 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

6. 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

7. 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

11. 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

12. 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

13. 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

14. 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

15. 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

18. 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

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

35. 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

36. 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 dentalcode@ada.org

37. 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

38. 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

39. 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

41. 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

42. 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?

43. 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

44. 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

45. 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

46. 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

47. 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

48. 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.

49. Resolving 3rd party issues • 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.

50. Resolving 3rdparty issues • 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.