Dental benefit plans do not cover the cost of all of the treatment needed by patients. A third-party payer has the right to deny benefits for services that are not covered by a customer’s policy. In these cases, the policy may allow no benefit or may allow the benefit it would have paid for a less expensive alternative treatment. Some policies, for example, do not provide any coverage for composite restorations – or crowns - but will provide coverage for this treatment at the rate allowable for amalgams. Here, the carrier is not suggesting that an alternative treatment is appropriate for this patient; simply that it is consistent with the plan’s allowable benefits. Such limitations help carriers to control premium costs.
However, some benefit decisions are based on a determination that the treatment is not appropriate, or that a less expensive alternative treatment is an appropriate alternative for this patient. Diagnosis and treatment planning are within the scope of dental practice – not dental benefit plans. A patient can dispute a reimbursement decision based on a carrier’s determination that an alternative treatment plan is appropriate for that particular patient. If a denial is based on a consultant’s opinion, the consultant is responsible for practicing dentistry in a manner consistent with the profession’s standards of care.
Dentists under contract with third-party benefit plans must first review their contracts to determine when and how they can dispute payment decisions. In New York, managed care plans are regulated by new state laws requiring specific protocols to appeal benefit decisions. Regardless, it is important that the patient first consider whether the basis for the denial of benefits is consistent with the terms of the benefit policy. Patients should review their policies and may consult with their employers regarding limitations and other problems they have obtaining reimbursement.
When a patient disputes a benefit decision based on the appropriateness of treatment, the customer can pursue four courses of action:
Before seeking an external review, the patient should review the specific benefit plan to determine the options and restrictions available for disputing a benefit decision. Generally, external review is only available after an initial internal review has been conducted. There are strict statutory time frames for requesting external review, so a patient must be familiar with his or her plan’s internal review requirements. A patient does not want to take too long on internal reviews and thereby forfeit the chance for an external review. The patient’s human resources manager or employer can assist. When a patient disputes a benefits decision, the patient [the dentist can assist the patient in filing for an initial internal review] may request in writing that the company reevaluate the claim. A copy of the explanation of benefits indicating the original denial should be enclosed. Patients should check their plan policies carefully to make sure that they submit all the materials necessary for an internal review. At a minimum, the letter should include the following:
The patient’s dentist may further assist the patient by providing copies of records or clinical justifications for the necessary care. A copy of a form letter that can be modified for particular situations follows.
I am writing as an authorized agent of my patient in response to the enclosed explanation of benefits sent to my patient and your insured, PATIENT’S NAME. I am writing on behalf of PATIENT’S NAME to request that this claim be reevaluated. While the explanation of benefits makes reference to the criteria used to disqualify this patient’s claim, it does not define the criteria for approving reimbursement for the treatment necessary for this patient. Please provide this information, as well as the name of the licensed dentist responsible for the review. In New York State, these doctors are responsible for their professional opinions when they render diagnoses of patients on behalf of third-party payors.
[for managed care plans]
Further, New York State law requires plans such as yours to make an initial internal review, as well as subsequent external, independent evaluation available. I am writing as the authorized agent of my patient to initiate this process.
[for insurance plans]
If your company cannot provide an impartial internal review of the appropriateness of this patient’s care by a qualified dentist, I suggest that you consider bringing this matter before the New York State Dental Association’s Peer Review and Quality Assurance Committee for an objective determination of the appropriateness of the treatment recommended. I maintain, based on my clinical examination and professional judgment, that the treatment plan I provided is the appropriate care for this patient. I do not believe the treatment plan proposed by your consultant is clinically appropriate for this patient. Based on this patient’s policy, he/she should be entitled to reimbursement for the treatment received.
To summarize, Treatment plan description/rationale. I have again enclosed copies of relevant radiographs and clinical records for the treatment.
If you would like to use the Dental Association’s Peer Review process for an objective determination of the appropriateness of the treatment plan proposed - or whether the plan supported by your consultant’s review is clinically appropriate for this patient and therefore applicable for benefits - please contact the New York State Dental Association, 518-465-0044, to request an Agreement to Submit to Peer Review to Establish Third Party Benefits and the associated Guide to Peer Review.
Contact NYSDA Health Affairs