Dental Insurance Claim - Denied Twice

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May 7, 2020
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My wife recently had some dental work performed on three teeth, diagnosed by the local dentist that resulted in three crowns. Specifically, the local dentist took xrays that revealed "three old restorations that were leaking, causing decay around the old restoration and severe sensitivity to my wife. When the initial claim was denied, the dentist wrote an extensive break down of the problem for each tooth and forwarded that to the insurance company. The dentist also provided the insurance company with "pre-operative x-rays, pre-operative intra-oral photos, post operative photos and post seat x-rays". The insurance company has stated that this claim "has been through 2 advisor reviews". I am not sure what that means, but it appears to me that the insurance company is second guessing the local dentist. How can I be sure that the insurance company is having a real peer review and not by some bureaucratic board of reviewers. Since the dental office has filed a second request for reconsideration and it has resulted in the same denial, I am afraid I don't know what steps to take next. Is there another source within United Concordia Dental Insurance Company that I can appeal my case to? Please help. By the way, the negotiated fee between our dentist and insurance company for this service is $1,915.56, and with our Hi-Option dental insurance plan, we were billed and paid 50% of the that cost, or $957.78. Without the insurance company reimbursement, it looks like we will be on the hook for the remaining amount.
 
May 7, 2020
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Thank you so much. Once I get the address, I will write them a letter. So what is more important, the local doctors opinion or the insurance review board? It seems to me that the review board has more clout, without even seeing a patient. Something seems wrong with this computation.
 

ADM

Apr 10, 2017
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I'm a dentist who does insurance claims review as a consultant. I can't speak to what your particular insurance plan does but our clients do indeed have licensed dentists reviewing all of their claims. Like SoCal said your insurance policy should state the specifics of the appeals process. When I have time later I'll list some reasons why your claim may have been denied and some tips for going forward.
 
May 7, 2020
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As an update to this thread, we have found an entire page in the insurance manual on what to do regarding a denial of claims. I appears that we have the right to request a third party review of our dental claim. So, we have written a letter (enclosed with the facts) requesting that our claim be reviewed by this third party. I understand the peer review process and what it is intending to avoid. Professional standards and training within the dental field should be consistence. With a dental procedure being performed in Florida, being reviewed by a review Board located in Pennsylvania, leave plenty of room for a difference of opinion. Who is to say who analysis is the best or correct one. ADM, thank you so much for your comments and I look forward to reading some of the reasons why our claim was denied.
 
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ADM

Apr 10, 2017
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First of all, your dentist should have been given a reason why the claim was denied. Did he tell you why United denied the claim? Here are some reasons/theories why your claim may have been denied:

1. The procedure codes and/or teeth numbers were incorrect. Just yesterday I had to deny a claim for the third time because the codes were incorrect. Each time the provider is told why the claim was denied, yet the same mistake keeps happening.
2. The crowns could have been approved but the crown build-ups were denied. This can make it look like the entire claim was denied when that's not what happened.
3. The x-rays submitted with the claims weren't diagnostic. This usually happens with film x-rays vs. digital. The films are either photographed or copied onto paper and submitted. That can distort them and make them unreadable. It can happen with digital images sometimes too.
4. The x-rays and photos don't get attached properly to the claim and the consultant doesn't see anything. The images can be assigned to the wrong payor ID or just never make it on the attachment at all. Think of it like sending an email without including the attachment you wanted to add.
5. The teeth could have been deemed too far gone to be saved. They could have advanced bone loss/gum disease or the decay is too extensive. It doesn't sound like that's the case with your wife. I'm just offering that as an example.
5. As consultants our clients are the insurance companies and they each have their own rules. It's possible the insurance company decided that crowns weren't necessary to repair the teeth. Instead an alternate benefit in the form of conventional fillings was assigned.
6. Our clients can request a peer-to-peer phone call. In this instance one of our consultants calls that dentist's office and speaks to either the dentist him/herself or to someone in the front office. If this option is available to your dentist I would suggest going this route, assuming scenarios 1-4 don't apply. I have found that providers really appreciate speaking to another dentist directly.
 
May 7, 2020
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ADM, your comments were great and specific. We really appreciate your perspective and the possibilities of why our claim was rejected. For the confused customer, the dental codes can be a big mystery. Your comment above " insurance company decided that crowns weren't necessary to repair the teeth " may have hit the nail on the head. We noticed on the Explanation of Benefits that the insurance company made the determination that "this service is a benefit only when the tooth is extensively decayed and/or fractured (not craze or crack lines) and cannot be restored with a direct restoration". Yet, when we (novice as we are) looked at the dental x-rays, it is apparent that the teeth in question are clearly and significantly decayed. Therein, lies the problem for us; one professional opinion versus the other, and we as patients are stuck in the middle. With your very informative write-up and our further reading of the rules, we are closer to understanding the rationale provided by the insurance company decision of our claim denial, as well as why our dentist did what he did. It appears to us that our dentist put the priority of his patient's health and well-being ahead of those who would question his reasoning for the procedures he performed. ADM, you are a big benefit to this forum, please continue to support people like me and others.
 
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weihlac

Verified Member
Jun 30, 2017
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ADM, your comments were great and specific. We really appreciate your perspective and the possibilities of why our claim was rejected. For the confused customer, the dental codes can be a big mystery. Your comment above " insurance company decided that crowns weren't necessary to repair the teeth " may have hit the nail on the head. We noticed on the Explanation of Benefits that the insurance company made the determination that "this service is a benefit only when the tooth is extensively decayed and/or fractured (not craze or crack lines) and cannot be restored with a direct restoration". Yet, when we (novice as we are) looked at the dental x-rays, it is apparent that the teeth in question are clearly and significantly decayed. Therein, lies the problem for us; one professional opinion versus the other, and we as patients are stuck in the middle. With your very informative write-up and our further reading of the rules, we are closer to understanding the rationale provided by the insurance company decision of our claim denial, as well as why our dentist did what he did. It appears to us that our dentist put the priority of his patient's health and well-being ahead of those who would question his reasoning for the procedures he performed. ADM, you are a big benefit to this forum, please continue to support people like me and others.
Remember that health and dental insurance companies are in business to collect premiums and deny claims to the limit of their ability. Insurance companies are not in business to "put the priority of his patient's health and well-being ahead of those who would question his reasoning". The insurance company's goal is to reward its stockholders. Paying claims is not a goal.
 

ADM

Apr 10, 2017
609
978
93
ADM, your comments were great and specific. We really appreciate your perspective and the possibilities of why our claim was rejected. For the confused customer, the dental codes can be a big mystery. Your comment above " insurance company decided that crowns weren't necessary to repair the teeth " may have hit the nail on the head. We noticed on the Explanation of Benefits that the insurance company made the determination that "this service is a benefit only when the tooth is extensively decayed and/or fractured (not craze or crack lines) and cannot be restored with a direct restoration". Yet, when we (novice as we are) looked at the dental x-rays, it is apparent that the teeth in question are clearly and significantly decayed. Therein, lies the problem for us; one professional opinion versus the other, and we as patients are stuck in the middle. With your very informative write-up and our further reading of the rules, we are closer to understanding the rationale provided by the insurance company decision of our claim denial, as well as why our dentist did what he did. It appears to us that our dentist put the priority of his patient's health and well-being ahead of those who would question his reasoning for the procedures he performed. ADM, you are a big benefit to this forum, please continue to support people like me and others.
You're most welcome. Your dentist can always appeal the decision and/or request a peer-to-peer consultation.
 
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ADM

Apr 10, 2017
609
978
93
Remember that health and dental insurance companies are in business to collect premiums and deny claims to the limit of their ability. Insurance companies are not in business to "put the priority of his patient's health and well-being ahead of those who would question his reasoning". The insurance company's goal is to reward its stockholders. Paying claims is not a goal.
While there's validity to what you've said you also can't deny that some of our colleagues share some responsibility. In the old days dentists would submit their procedures with no x-rays, photos, or any other documentation. The claims would be paid without question and that led to abuse and fraud. Things had to change and as a result legitimate treatment is under further scrutiny.