Why dental insurance companies will sometimes "reject" a dental procedure?


Dental insurance companies hire people to review the pre-certification claims submitted by dentists. Sometimes their "consultants" are dentists and sometimes they are not. Usually they judge the need for a crown based on the percentage of the tooth restored with fillings. If they feel that they are not sure a tooth really requires a crown they will reject the claim and ask for additional information before authorizing the proposed treatment plan. This can include a written narrative or supporting photos.

They maintain that their claim reviews cut down on work that is unnecessary. That being said, their rejection of claims and their request for more information has the effect of delaying non emergency treatment and during this time a patient may change their minds and decide not to proceed with a proposed treatment. Probably insurance companies are aware of this fact. Also they have a conflict of interest. They are obligated to attempt to make as large a profit as possible, since they are ,after all , mostly publicly owned companies and as such have a responsibility to achieve maximum profits for their shareholders

To be fair,consultant reviews do cut down on fraud and needless dentistry, but lately, our practice has been receiving more and more requests for additional information on our pre-certification requests. We always cooperate by writing a short narrative or submitting additional photos or radio graphs.

Some procedures, such as night guards or crowns are not paid for because the insured's contract specifically does not allow for payment for that category of dentistry. The insurance company does not imply that the procedure is unwarranted. They just explain that it is not a covered procedure in the plan that was purchased by the patient's employer. Also, if the dental work being pre-certified  was recently done and now needs to be replaced, most insurance plans have minimum amount of time that a restoration has to be in service (5 years or more for crowns) before they will cover its replacement cost.

from Ask Dr. Spindel - http://ift.tt/2ptZnTa - http://ift.tt/1SpPbm6

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