Should the carrier talk to you?

A business coach asked: 

My offices here and Washington are having issues getting Delta Dental to cover Perio. They have had approximately 30% of their recent claims did not. They said that their response from Delta has been that the Perio does not qualify. There is clearly angular bone loss on the x-rays and significant probing depths with bleeding. Has there been a change in what Delta is paying for?

Patti responded:

I have heard about WA Delta before. My question is what documentation has been sent? How was it sent? Was the claim auto-adjudicated?

That last question is important. Carriers prefer auto-adjudication which means, a machine with an algorithm is reading it. That costs them about $1/claim. When a claim is thrown out of auto-adjudication and a human has to read it, they is costs them $4/claim. The problem with auto-adjudication is it looks only at the procedure codes.  My guess is the algorithm was changed to reject more. Why? That I don’t know. Was it an overall decision by Delta for all the policies they write? Perhaps.

But I wouldn’t leave it there. The challenge is what you can do and what you can’t accomplish. The carrier can and often will choose to only talk to the client. You are not their client. The office may or may not be depending on if they signed a contract or not. The patient under the contact is the beneficiary of something that is most often chosen by an HR person. No good or bad guys here, just a situational analysis.

Have any of these offices asked for clarification of what the specific parameters required for coverage under a specific policy? Have they asked to see it in a contract? Often this doesn’t happen. When carriers say no, offices get frustrated and complain yet may not do what is needed.

Further, do the office write a narrative that fits in Box 35 Remarks that clearly indicates the medical necessity that includes a diagnosis for the treatment? It is not a HUGE narrative rather more a Twitter-Style. Let me give you an example:

  • Sinus issues, GERD, possibly pregnancy. High risk caries fluorescence  1.5-2.5. Thermal sensitivity. 45% Type 2-3 inflammation. Dx: Gingivitis-dental biofilm induced mediated by systemic or local risk factors

That’s 208 characters. As a clinician, I am sure you readily see exactly the circumstances for this patient.

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