Let me give you this scenario:
A patient frantically walks into your practice… in pain… saying they need help and it’s an emergency.
You rush them to the back and check to see what’s going on in their mouth.
Uh-oh. Looks like they may need an extraction.
You tell the patient this and they tell you “can you save the tooth”?
You say “i’m sorry, if you want to get out of pain right now, we would need to do an extraction… however what we can do is revisit it to place an implant”.
The patient says “YES! Let’s do that”
This is all happening while your front office is verifying the patient’s insurance and making sure you get paid for what’s about to happen.
Boom. The insurance company denies a procedure.
Not the extraction… but the implant… or wait… it’s the bone graft… or wait… what is it?!
Why is it being denied?!
All this is happening while you already started working on the extraction…
What’s happening and how can you avoid anything remotely close to this?
In this article you will find out two of the most commonly denied procedures from insurance companies. This is incredibly annoying and I want to make sure you can just glide right through when these procedures come up in your office. You will also learn 2 solutions to overcome the denied claim from these procedures.
Let’s dive in!
THE FIRST MOST COMMONLY DENIED PROCEDURE BY INSURANCE COMPANIES
One of the most important procedures, that get denied often, typically has something to do with extraction, bone graft, and implants. Many different insurances have very different guidelines on how they want to tackle that.
Here’s a good example:
Every single time that you are “extracting a tooth and placing bone back in there”, a bone graft, you want that tooth to heal, and in about three to four months, it's ready for an implant to get placed. There are many, many “gotchas” and “issues” that happen with that. Fundamentally, I think everybody needs to understand what is happening and how our insurance companies are getting you.
Most front office staff or whoever is in charge in your practice to verify and call the insurance company, when they're doing insurance verifications, they'll take a look at bone graft and they'll say, "Oh, it's covered at 50%, awesome. Let me go excitedly tell the patient that even though it's $600, $700 bucks, your insurance is saying they'll cover $350 bucks, and your copay today is $350."
There’s a caveat to that.
You cannot do the bone graft and extraction on the same day! Which, if you ask any clinician, they'll say, "How's that even possible?" From a clinical standpoint, you have to do it on the same day. The insurance company is basically saying, "Oh yeah, we will cover it as long as you don't do it on the same day."
Seriously?! How has the ADA allowed that? It's so blatant. It's almost like mocking the dentist saying, "Aha, clinically, yes, you have to do it the same day and we are saying we'll approve it, only if you do it in the nonclinical way."
THE SECOND MOST COMMONLY DENIED PROCEDURE BY INSURANCE COMPANIES
The second thing is that most insurance companies will deny it if there is no pre-authorization of an implant there. Because what they're saying is, "We will only approve it if you demonstrate to us that you've planned to do an implant."
I don't know if it's ignorance on the insurance behalf or just deliberate little “gotchas” to deny claims, but in reality, what happens is somebody comes into the office with a toothache and it's an emergency. The patient is literally saying “I'm in pain, do something." The doctor says, "You need an extraction. This tooth is not something that we can save or not worth it. We can extract it, but if you want to eventually place an implant where we are doing the extraction, we need to do this bone graft procedure."
Even if the insurance says, "Yeah, we'll cover it even if it's on the same day of extraction," you still now have to worry about this other clause that there is no pre-authorization for an implant. You can't really do a pre-authorization for an implant because the patient is in the chair in pain right now.
It's not like you can just tell the patient “hey patient, we're going to send a pre-auth just so that it's in their record that we intend to do an implant. Once we get this pre-auth back in two weeks or so, then you come back and then we will do the extraction."
Do you see how the insurance game can be WAY more difficult than it really needs to be?!
Patients don’t see this, only you do. So what now? What can you do to try and overcome these procedures?
HERE’S A SOLUTION!
One thing you can do is have a letter already written down that is basically signed on behalf of the patient that says:
"I came to [your practice’s name] and I was in pain. I wanted to:
A: Save the tooth, which was not feasible.
B: I want to replace it with an implant and have a tooth back in there in the future, but because I was in excruciating pain, the doctor had suggested that we basically first fill it with bone graft so that it's eligible for an implant in a few months.
I fully intend to get an implant done once my bone grows back, I just couldn't wait for a pre-authorization."
This letter may just be able to save you and get your procedure paid in time by the insurance company!.
Whenever you have a PPO patient who needs an extraction, bone graft, or implant, you should be on high-alert! Tell yourself:
"Okay, I am now navigating this minefield of these “aha! gotcha!” from insurance companies and nothing that they say makes sense, but what can I do to make sure that this gets paid."
Another thing you can do is build a “cheat sheet”.
Now this is a little bit more of a trivial thing that is found very often, and this is somewhat controversial, and it's totally dependent on the office and how you want to manage things, but a lot of different insurance companies handle how they're going to pay for a procedure differently.
You're going to find some insurance companies, for example, for a deep cleaning SRP, they are okay with four millimeters. It's going away more and more insurances are now saying five millimeters because in 2019 or 2020, there was a new code introduced called D4346, but there are still people who are unfamiliar with that.
The policy was always that if there are multiple four millimeter pockets, they would do a deep cleaning, but you probably need to have a “cheat sheet” in your own office of which insurance will cover that. Because what will happen is if you're sending it to an insurance company that needs over five millimeters, they're going to deny it.
Beyond that, there's even further complications because there's another code called one to three teeth. It’s basically if the pocket had five millimeters, but only in one to three teeth, they'll deny the bigger code called 4341. Some of them will all go down with the code 24343, which is one to three teeth. Some of them will just deny it. These are things that you just have to be very cautious of.
The best way to be cautious and consistent is by building your “Cheat Sheet”
Build a cheat sheet of how different insurances handle some stuff. For example: four bite wings plus 2A, two PAs and a panoramic to get re-bundled to a full mouth x-ray is very common, but it's at the insurance carrier level, not policy level, which means Delta Dental will always downgrade four bite wings, two PAs in a pan to an FMX. All that means is the total amount that comes up may be $180 bucks for that, but if the cost of a full mouth x-ray that they're paying is $120, Delta Dental will pay $120. Other insurances, like Aetna, will pay the full $180 separately.
Your cheat sheet should basically tell anyone who is looking at it this: "This is how this insurance company tackles this."
This is important to understand. Even if you're in network or out of network with insurance companies they can still deny procedures.
Therefore start creating your “cheat sheet” if you haven’t, create your “pre-auth” letters and get familiar with the insurance companies that deny specific procedures. Create a system to navigate around that “denied claim” and keep moving forward!
p.s. about 2 years ago I did a podcast episode with Vivek Kinra (owner of PPO Profits & Verrific) where we started talking about the most common and popular procedures that insurance companies deny. This article is based off of that episode which you can listen to here: https://thedentalmarketer.site/podcast/mmm-insurance-2