OPTIONS FOR DENTISTS IN ADDRESSING DENTAL INSURANCE PROBLEMS AND COMPLAINTS
Dental insurance is often instrumental in getting patients into a dental office because it assists them in paying for dental services they may otherwise not obtain. Dental insurance is also, unfortunately, a source of aggravation and frustration for dentists when certain claims for dental services are handled in a way that is disagreeable to the dentist.
Many times, when dental insurance problems occur, Ohio Dental Association member dentists contact the ODA with questions about their options in addressing the problems.
Appealing denied claims
The most obvious response is for the dental office to appeal the denial. What is not always obvious, however, is what to include in the appeal to increase the chances of success in getting the denial overturned.
Numerous insurance companies have reported to the ODA that many dental offices appeal the denial by simply resubmitting the same claim that was initially denied. They additionally report that in appealing the denial the dental office does not address the insurance company’s reason for denying the claim, i.e., the reason stated on explanation of benefits (EOB). Either action will typically lead to a denial of the appeal and more frustration for the dentist.
“Many dentists view dental insurance as a game and the biggest impediment to playing the game is not knowing the rules,” said Dr. Tracy Poole-Swerlein, chair of Ohio Dental Association Council on Dental Care Programs and Dental Practice. “The insurance companies themselves often provide good insight to these ‘rules’ and knowing them can assist dental offices in either minimizing initial claim denials or successfully appealing denied claims.”
The most obvious insight for addressing a denied claim can be found on the EOB that accompanies a denied claim. Directly addressing it by including with the appeal information the insurance company did not have when the initial claim was submitted will increase the chances of getting the insurance company to overturn the denial.
Oftentimes insurance companies include the clinical and/or documentary criteria they want to see met in order to provide reimbursement for various services. These criteria are typically found in the carrier’s dentist handbook, participating provider handbook, office reference manual, dentist reference guide, or other similarly titled document.
These documents may also detail specific steps to follow when submitting appeals and/or options the contracting dentist has to resolve disputes with the plan.
“While not a guarantee of payment, providing the insurance company with the information it states in writing that it needs via the EOB or the company’s participating provider handbook will certainly increase the chances of success,” said Poole-Swerlein. “It also helps lay the groundwork for taking the matter beyond the insurance company to the ODA, insurance regulators or even the courts.”
Additional dental insurance resources, including resources for appealing denials, can be found on the ODA (https://www.oda.org/member-center/resources/dental-insurance-assistance/) and American Dental Association (https://www.ada.org/resources/practice/dental-insurance) websites.
Involving the patient/subscriber
Pending the nature of the denial, its impact on the patient’s financial liability to the dentist and the dentist’s relationship with the patient, it is oftentimes prudent to involve the patient in addressing the denial. This can be done by updating the patient on what’s going on with the claim and what the dental office has done to get it paid on their behalf. After describing the problem, the dental office can ask/suggest to the patient to contact their dental benefit plan sponsor, which is typically their employer, to request assistance in getting the claim approved. The gist of the request is that the patient appreciates their employer’s sponsoring a dental benefit plan but is concerned that they are not getting the benefits they’re entitled to from their plan. If the patient is not comfortable with the details of the claim and/or its denial, then they can simply ask their employer’s human resources office to either make a call to the dental office or accept a call from the dental office to learn the specifics of the situation.
ODA Dental Insurance Working Group
If the dental office is unable to resolve the matter on its own, then ODA member dentists may want to consider involving the ODA. For the past 20 years, ODA member dentists have volunteered to serve on the ODA’s Dental Insurance Working Group. This panel of dentists is empowered to act on dental insurance questions, concerns and complaints that are submitted to the ODA by the membership and require some type of formal involvement by the ODA, including going to a particular insurance company on the dentist’s behalf.
ODA members who would like to utilize the working group’s services may do so by submitting the details of the case to the ODA via the ODA website (https://www.oda.org/member-center/resources/dental-insurance-assistance/), email (dentist@oda.org), fax (614-486-2893) or mail (1370 Dublin Road, Columbus, Ohio 43215).
Everything that was submitted to the insurance company and the carrier’s responses should be submitted to the ODA, e.g., a description of the situation, claim, appeal, denial (complete EOB), photographs, radiographs, charting, clinical findings and relevant notes (e.g., if the patient was in pain or sensitive to hot or cold or had bite sensitivity), etc. All patient identifiers should be redacted from everything that is submitted to the ODA.
The Dental Insurance Working Group’s services are free of charge but only available to ODA member dentists.
“The Dental Insurance Working Group has worked hard over the years to address dental insurance matters of direct concern to many individual dentists,” said Poole-Swerlein. “Its services are a tremendous membership benefit and I encourage ODA members to take advantage of this service when they encounter dental insurance problems that they are unable to resolve on their own.”
Ohio Department of Insurance/U.S. Department of Labor
There are times when it might be necessary to involve government regulators in an insurance problem. Generally speaking, regulators are tasked with ensuring patients/policyholders receive the benefits to which they’re entitled. In cases where they aren’t, dentists may want to consider directing the aggrieved patient to the Ohio Department of Insurance to file a consumer complaint (https://insurance.ohio.gov/consumers/resources/how-to-file-insurance-complaint).
Patients may also have the option of filing an external review complaint (https://insurance.ohio.gov/consumers/health/understanding-health-coverage-external-review-appeal) with ODI for certain claim denials.
Dentists themselves may also be able to file a complaint with ODI for certain prompt pay or credentialing matters (https://insurance.ohio.gov/about-us/complaint-center/provider-complaint-options).
The courts
There are times when the only option to resolve a dispute with an insurance company involves use of the legal system.
Patients can utilize the argument that they are not receiving the benefits they’re entitled when going to court. While dentists typically do not have this argument to use in court, a dentist may need to utilize the legal system to enforce the terms of their participating provider agreement with an insurance company.
