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How to Deal with Payer down Coding Your Dental Practices?


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Two of the most malicious activities that occur with dental claim reimbursement are payer down coding and payment bundling. This leads to negative bottom line and on that a derailed income cycle, which you don’t want.

On that note let us first understand what is it and what can you as a dentist do about it?

Claims bundling is simple terms means the systematic combining of distinct dental procedures by third-party payers that results in a reduced benefit for the patient/beneficiary. Whereas, down coding is a practice of third-party payers in which the benefits code is altered to a less complex and/or lower cost procedure than was reported except where delineated in contract agreements.

It stands vital for not just dental, but overall healthcare facilities to learn the differences between bundling of procedures and down coding.  If you don’t distinct the same, its time you hire a professional dental medical billing and coding company that will help you learn the nuances of down coding and bundling.

Down coding means the adjudication of claims in a manner that reduces dental procedure codes to a less complex or lower-cost code, unless expressly provided for in the CDT Code of Dental Procedures and Nomenclature. This does not include the denial or adjustment of claims for covered services in accordance with the terms of a member’s dental benefits plan.

Professional medical coders do not automatically change a dentist’s submitted procedure code to a less complex or lower-cost code, subject to the following:

  • A submitted code may be changed when a professional review of the submitted charges and supporting clinical information such as x-rays, photographs, periodontal charting, narratives, and treatment notes, indicates that the original coding may have been inappropriate;
  • Specialty billers will adjudicate claims in accordance with the terms, exclusions and limitations of a member’s dental benefits plan, including, but not limited to, any contractual alternate treatment/alternate benefit provisions (ABP).

 Medical Filing Tips for Dental Accident Claims

When submitting a claim for a dental injury to an insurance provider, it is important to remember that not all injuries to teeth are classified as trauma. Some insurers define dental trauma as a ‘non-biting injury to a sound natural tooth.’

For this reason, if a person ruptures a tooth while biting into a popcorn kernel, the restorative services are not likely to be covered under a medical policy. Furthermore, the health of the tooth prior to trauma can also play a role in determining coverage. Healthcare payers most often only pay to restore sound natural teeth. A sound natural tooth is often defined as a tooth that is stable, functional, and free from decay and advanced periodontal disease and in good repair at the time of the accident.

According to some insurance plans and their policies - "Teeth must be free from decay, in good repair and firmly attached to the jawbone at the time of injury."

Some describe a sound tooth as a ‘virgin or unrestored tooth.’ Others consider a tooth sound only if the injured tooth had no decay, no filling on more than two surfaces, no gum disease associated with bone loss, no root canal therapy, is not a dental implant, and functions normally in chewing and speech.

So as you can see, the definition of a sound natural tooth can vary from payer to payer, which is also true of pain related medical benefits.

 Check the insurance coverage limits

Coverage for dental pain is entirely plan dependent, which is why it is essential to contact each patient's medical carrier to determine his/her medical plan guidelines. Some dentals plans for instance will only provide dental suffering coverage for the first 24 hours after an accident. Others require that the patient be seen within 72 hours of the accident. Then there are some who require notification, not necessarily treatment, within 72 hours of the accident unless there are justifying circumstances (like if the patient is in the hospital for the three days following the accident).

It is wise to have the insured member also contact their medical insurance as there are payers that require notification by the enrollee in order to prevent reduced or denied benefits. Payers also most of the time has specific time frames in which pain related dental billing services must be completed. One payer may require treatment to be finished within twelve months, while another may require repair or replacement within the calendar year of the accident or during the next calendar year.

The importance of contacting each healthcare payer to clarify the patient's coverage guidelines is critical is getting faster and full reimbursement.  

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