Constituent Dental Care/Practice Chairperson’s Resource Manual September 2010 Originally Published: August 1992 Revised: November 1994 Revised: February 1997

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Draft Response to Limitation of Benefit Based on UCR

Patient Name

Complete Street Address

City, State, ZIP

Dear (Insert Name):
You recently contacted my office to let us know that your dental insurance benefit program provides coverage for (specify type of treatment) at a rate lower than the fee you have been charged. I would like to take this opportunity to explain to you why my fee for this service differs from what your carrier may have called the “usual, customary and reasonable” fee.
My professional philosophy is to develop and follow treatment plans that are based on what was in your best interest for maximum improved or maintained oral health care. My treatment decisions are not based on what services or fees are approved under your dental insurance program. In fact, it is not uncommon for dental insurance plans to provide their subscribers with less than optimal benefits. My fees are based on three elements—the cost of overhead to operate my practice, the cost of delivering the treatment that you and I have selected, and the cost of the time involved in providing you with this care.
You do not benefit if the recommended treatment is compromised for the sole purpose of accommodating a third party’s maximum benefit allowance.
If your dental insurance carrier has a qualified dentist on staff who reviews claims, I would be happy to discuss your case with this individual. I would hope that after reviewing the treatment plan and specifics of your case, the dental consultant would be better informed to take a stand regarding this case.
You should be aware that insurance carriers frequently base their determinations of “usual, customary and reasonable” fees on out-of-date information or they may not take into account certain local factors that affect the fees for various services. In any case, you may be assured that for all of my patients, I base my treatment decisions upon my best professional judgment, not upon the patient’s third-party carrier’s dental benefits plan.
Please contact me with the name and telephone number of your carrier’s dental consultant in the event that you would like me to review the specifics of your case with that individual.
Sincerely yours,

Your Name

When a Carrier Changes the Original Treatment Code:

AGD membership surveys have indicated that 75 percent of our members perform non-surgical periodontics. Many carriers have become increasingly concerned about the expense of honoring claims for periodontal care, while practitioners remain concerned with the ability to properly provide the care their patients require. In recent years, carriers have begun to seek more specific information from dentists regarding periodontal therapy. They question methods of treatment and sometimes change treatment codes in order to pay benefits at a lower level. In fact, some dentists provide therapeutic periodontal procedures and are paid at prophylaxis fees.

Codes for periodontal disease vary according to the level of disease a patient may have and the provider’s method of treatment. Providers need to be certain that they understand the proper use of each code to ensure that patients receive their entitled benefits and the necessary and appropriate treatment. One way to lessen the possibility of claims being questioned and codes being changed is to complete the narrative portion on the patient’s claim.
When a member advises you that a carrier has denied a patient’s benefit by changing the treatment code, advise him or her to direct a polite and informative letter explaining how the diagnosis was reached and how the patient’s treatment relates to the code’s definition.
It may also be helpful to provide the carrier with copies of the patient’s chart, X-rays, and drawings to support the provider’s diagnosis and treatment.
Both the AGD and the ADA recommend reporting all instances of downgrading of codes by carriers to the state insurance commissioner and to the patient’s employer.
Draft Response to a Carrier Changing the Original Treatment Code

Name of Carrier Executive


Name of Carrier

Complete Street Address

City, State, ZIP

Dear (Insert Name):
One of our members has expressed concern because (insert carrier’s name) has denied a patient proper reimbursement by changing the code for periodontal disease treatment.
The Academy of General Dentistry, an organization of approximately 35,000 general practitioners, fosters continuing education for general dentists and encourages them to continually update their knowledge so that they can be more effective in rendering patient treatment.
(Insert a paragraph about the code’s definition and how it specifically relates to the patient’s diagnosis and treatment.)
While we are sensitive to your desire to control health care expenditures, we believe that by changing codes, you are misleading the patient and second-guessing the doctor’s diagnosis. I urge you to review this estimate and revise it to cover the appropriately prescribed and delivered periodontal disease treatment.

Your Name

Constituent Dental Care/Practice Chair

Academy of General Dentistry

Denial of Benefits When Treating Family Members:

Many insurance companies have policies against reimbursing subscribers for treatment costs when care is rendered by a family member, claiming that health care professionals do not bill their spouses, parents, siblings or children. While this is not always the case, and while the patient should be allowed the freedom of choice to select a dental health care provider regardless of a familial relationship, the fact remains that the contractual provisions of many third-party plans disallow payment of benefits when there is a familial relationship between the provider and patient.

AGD membership surveys have indicated that 21.1 percent of dentists have reported denial of benefits when treating a family member. While plan subscribers pay premiums for the dental benefits, their freedom of choice is often limited by the exclusion of situations when care is provided by a member of the family. There is little chance that an appeal of this policy will be successful if this exclusion is stated in the plan’s contract or provisions. An appeal may be successful if a benefits policy is changed and the insurer or carrier fails to notify subscribers.
Denial of Payment for Covered Procedures per the Contract Language:

Nearly every dentist whose patients have dental insurance has experienced the situation when a third-party insurer denies payment for a procedure that the provider felt should have been covered under the language of the contract. An AGD membership survey indicated that 70.2 percent of all respondents experienced this problem. If this should happen to you, bear in mind that insurance companies typically don’t deny payment arbitrarily—if you’re willing to investigate the case, chances are you’ll discover the reason for the differences of opinion.

No one is immune from human error, be they your employees or the employees of an insurance company. When a claim is rejected, the first thing you should do is review the information available to you. Review the limitations of the contract. Make certain that you submitted the correct procedure code number. Determine whether the patient has run out of dental benefits for the year. Verify that your office followed the instructions established by the insurance carrier, such as making certain that written explanations were provided for those procedures requiring a narrative account.
Once you determine that correct submission procedures were followed and that the patient was not at the limit of his or her benefits, call the carrier to determine why the claim was denied. Discuss the case with someone other than the claims processor, preferably the dental consultant or someone from the provider relations department. Offer the facts about why you believe the treatment provided was covered under the benefits contract. Follow the steps outlined in the AGD Checklist for Resolving Problems with Carriers.
Your chances of affecting change likely depend upon the responsiveness of the carrier. Keep in mind that pre-determination of benefits could help minimize this problem.

Professional Courtesy:

Unfortunately, cases involving one dentist making disparaging remarks about another dental professional occur all too frequently. These situations are probably among the most frustrating since they indicate a lack of professional courtesy and behavior from other practicing dentists and may serve as evidence in a malpractice lawsuit. In any case, the most effective approach calls for you to be professional, practical, and correct in your expectations, as well as courteous in your approach. You may be able to successfully resolve this type of incident by following these key steps:

  • Contact the individual who made the remark directly. Establish dialogue and suggest talking about it over lunch.

  • Contact your local or state dental association to have this adjudicated through an ethics committee, since speaking disparagingly of colleagues could be considered a breach of ethics.

  • Seek legal redress through an attorney. This will create bad feelings, but it can be effective in ending the problem.

In addition, the ADA’s Principles document states in Advisory Opinion 4-C that dentists are under obligation to report to “appropriate reviewing” agencies any “gross or continual faulty treatment by other dentists.” This does not mean a dentist may harshly criticize a colleague to the public nor does it allow a practitioner to suggest that a non-specialist also providing general specialty services is unqualified to do so.

Loss of Radiographs:

An AGD membership survey indicated that 52.2 percent of respondents reported loss of radiographs as one of the problems they encounter with third-party carriers. There is little an individual practitioner can do to prevent a third-party carrier from misplacing the radiographs of subscribing patients. As a result, the most effective precaution you can take is to always send duplicate copies and maintain the originals of all radiographs in your own files. Some practitioners take what is known as “double pack” radiographs in order to ensure that they have a second copy. Others take two pictures or have a duplicating machine in the office to make certain that they’re able to satisfy the needs of the third-party carrier and maintain the integrity of their own files. This is especially important because in the event of a lawsuit, radiographs would be important part of the provider’s defense.

Of course, doubling up on radiographs as a preventive measure involves additional expense. Since it’s impossible to predict which patients’ dental insurance plans will require radiographs, it’s next to impossible to know which patients should undergo “double pack” radiographs. Many practitioners are not comfortable going through the efforts and cost of duplicating all radiographs or find it difficult to charge patients for the fees associated with meeting the requirements of their dental benefits plans. Yet few third-party carriers have policies that reimburse providers for the cost of supplying duplicates of radiographs, and although it should not be the case, the provider most frequently bears the cost of duplicating radiographs. However, many practitioners prefer this option to risking the loss of original radiographs by submitting them to third-party carriers.
With the onset of digital technology, duplicates may become less of an issue. Digital radiography is a contemporary modality with increasing use that will likely enable you to send copies of X-rays while maintaining the original.
Misdirected Payment of Benefits:

In situations when payment was issued directly to the patient despite the assignment of benefits, most third-party payers will acknowledge and correct the mistake, although in some states they may not be obligated to do so. In cases when the benefit check is issued to the patient by mistake, contact the patient, indicate the situation and request that payment be remitted to your practice. If the patent refuses to cooperate, turn the account over for collection and notify the patient’s employer.

If a particular carrier consistently takes an excessive amount of time to process claims or often loses them, you may wish to send future claims by certified mail. However, you should remember that unless a written agreement exists to the contrary, the third-party carrier’s responsibility is to the patient, not the provider.
Periods of Patient Ineligibility:

Many dental insurance benefit programs delay patient eligibility for coverage for a certain time period initially after enrollment. Other programs allow only basic services for a given time frame, and require a longer period of participation in the plan before covering other services, such as periodontal care. Other plans have been known to require patients to complete an “evidence of insurability” form, which the carrier deems is a necessary and sound business practice that prevents patients from engaging in “adverse” selection, or in the selection of dental coverage only during the time period that they expect to need extensive treatment. Third-party carriers use each of these mechanisms to control or contain the costs of providing care to their subscribers.

There is little the provider can do to counter the carrier’s restrictions on subscriber eligibility.

The acts of submitting a treatment plan for pre-determination or of pre-certifying a patient’s eligibility do not guarantee payment of benefit. It’s critical that the health care provider have a thorough understanding of the nuances, and commitments, associated with each of these terms. The ADA’s official definitions of each term are outlined below; however, it should be noted that their use by third parties is not consistent.

  • Pre-certification: Confirmation by a third-party payer of a patient’s eligibility for coverage under a dental benefits program.

  • Pre-determination: An administrative procedure that may require the dentist to submit a treatment plan to the third party before treatment is begun. The third party usually returns the treatment plan indicating one or more of the following: patient’s eligibility, guarantee of eligibility period, covered services, benefit amounts payable, application of appropriate deductibles, co-payment, and/or maximum limitation.

Reduced Benefits for Non-contracting Providers:

Nearly 64 percent of the respondents to an AGD membership survey reported diminished payment of benefit because they were not a participating provider; this problem has shown a great increase in frequency over the past two years.

While more providers are participating in a wider variety of dental benefits plans, at some time every practitioner experiences the situation where payment of benefits are reduced because you are a non-contracting provider. In these instances you must contact the patient who is responsible for paying any balance due. Upon welcoming a patient into your practice, you should consider asking the patient to read and sign a statement agreeing to assume financial responsibility for any treatment, regardless of the amount of benefit paid by a third-party carrier.
Two-Tiered Reimbursement Systems:

The AGD opposes separate fee levels to specialists providing the same or similar services as general practitioners. When a general dentist performs a procedure that he or she is licensed to do, reimbursement should be the same as that provided to a specialist. Two-tiered reimbursement practices reaffirm a caste system within the profession, implying that specialists are worth more simply because they’re specialists.

Yet patients also suffer under two-tiered reimbursement systems. If a patient is reimbursed at a lower rate when being treated by a general dentist instead of a specialist, the carrier is suggesting that the subscriber should receive care from a specialist, even though treatment by the general practitioner may be more reasonably priced. If the subscriber is not aware that the reimbursement will be less if care is rendered by a general practitioner, then the individual receiving care is penalized because although the patient is paying a set premium regardless of who delivers care, the reimbursement level for care rendered by the general dentist will be lower than that given for specialist care.
Unfortunately, two-tiered reimbursement systems are a problem common among general dentists. Over 52 percent of the respondents to an AGD membership survey reported diminished payment of benefits because they were general dentists, not specialists.
Changing these types of practices requires a great deal of carefully coordinated communication, but often the outcome is worth the effort. For instance, the AGD recently was successful in convincing a dental insurance plan in the northeast to change a two-tiered endodontic reimbursement practice. Upon being advised by a member that a carrier is engaged in a two-tiered reimbursement system, your best approach may be to contact the carrier and detail the detriment of such a practice. Be certain to send copies of the letter to the member advising you of the situation, the Chairperson of the Academy’s Dental Practice Council, the AGD Director of Dental Benefit Programs and Dental Practice, and the individual at the state dental association who is responsible for dental care issues. A sample letter follows.

Draft Response to Two-Tiered Reimbursement Practices

Name of Carrier Executive


Name of Carrier

Complete Street Address

City, State, ZIP

Dear (Insert Name):
One of our members has expressed concern regarding a recent practice by (insert carrier’s name) of a (specify type of treatment, such as endodontic, orthodontic, periodontic, etc.) reimbursement program that pays (insert type of specialist, such as endodontist, orthodontist, etc.) more than general dentists for rendering identical services.
The Academy of General Dentistry strongly believes that fees should be determined by the complexity of the procedure, not by whether a practitioner specializes in a particular area of dentistry.
I am certain that you are aware that there is a hierarchy of dental services associated with any specialty area. General dentists often perform services at the lower end of the hierarchy and refer the more complex cases to specialists. Generally, the fees of a general dentist also tend to be at the lower end of the hierarchy. If the general dentist is qualified to deliver the same treatment as a specialist, it is in neither your best interest nor the patient’s best interest to reimburse the specialist at a rate higher than the general dentist.
You should be aware that your policy is also detrimental to your plan’s subscribers, who may not be aware that the reimbursement will be less if care is rendered by a general practitioner. The subscriber to your plan pays a set premium regardless of who delivers care. It is unfair to penalize the subscriber for electing to receive care by a general dentist. In addition, by advocating that patients receive care from specialists in order to maximize their benefits under your program, you are suggesting that the subscriber receive care from a specialist, who is almost certain to charge more than a general dentist for providing the same treatment. As a result, you are ultimately increasing the sum of the reimbursements payable to participants in your plan. I feel confident in presuming this was not your intent.
We ask that you review this two-tiered reimbursement program and the inequities it creates for all parties involved.

Your Name

Constituent Dental Care Chair

Academy of General Dentistry

Unreturned Referrals:

These situations rate among the most frustrating experiences, since they indicate a lack of respect for another professional’s practice. Most dentists typically refer patients in need of more specialized care to other providers with whom they’ve established a professional rapport. Referring relationships are established on the basis of respect for another provider’s skill and reputation. For such a relationship to remain strong, both providers rely upon continued goodwill and follow-up communication as necessary.

Few dentists receiving referred patients for more specialized care would neglect to contact the referring practitioner to discuss the outcome of a case as this could have a negative impact on future referrals. However, if you have referred a patient to another dentist and have not received a follow-up report, contact the dentist by telephone and inquire into the specifics of the case, such as what treatments were performed and whether there were any problems or if the patient experienced any pain. It’s likely that your colleague had planned to contact you regarding this case, but that time had elapsed faster than expected.
If you are frequently required to make follow-up phone calls to a specific practitioner, or if it is routinely a negative experience, you may wish to discontinue referring patients to that provider.
Utilization Reviews:

Utilization review is a procedure usually undertaken by a third party or an entity that has been created expressly for this purpose. The goal of utilization review is to determine how often individual dentists are performing certain procedures and then compare the frequency of these procedures with other dentists who have also had this determination done. Usually the review, done with the aid of computers utilizing submitted dental insurance forms, will determine for example how many crowns are done per 100 patients, or how many scaling and root planings are done per 100 patients. These ratios are then averaged and the dentists are compared to each other. Carriers may arbitrarily determine a cut-off point beyond which any dentists whose ratios for specific procedures fall beyond this are deemed “outliers.” In other words, the carrier has determined that they perform these particular procedures far in excess than do their fellow dentists. In some instances, the carriers will contact the dentist and discuss with him or her the reasons why they may be doing certain procedures to a much greater degree than their colleagues.

Subsequent to this, the dentists may be “encouraged” to bring the number of these procedures performed into line with what the carrier has deemed acceptable. If the dentist is a contract dentist and has not complied with the wishes of the carrier with regard to cutting back on the number these specific procedures performed, he or she may be asked to leave the network. If the dentist is not in the network, prior authorization may become a requirement. Still other carriers may insist on a review of the patient records and if appropriate and adequate (as determined by the carrier) substantiation for the performance of these procedures is not found in the records, the carrier may determine that much of the treatment rendered was unnecessary and may ask for financial reimbursement. Often, unwittingly, dentists agree to abide by these rules and to allow the carriers to enforce arbitrary regulations regarding utilization review by signing a contract without carefully examining it or understanding it. It is important, as with any contract, that you carefully review and evaluate the conditions and rules of a contract prior to signing the contract. If you have questions regarding any contract, you may contact the ADA contract analysis service or the AGD’s Director of Dental Benefit Programs and Dental Practice.
If you are contacted by a member who is notified by a third-party carrier who claims that the practitioner performs a specific procedure with much greater frequency than other local practitioners, your best response is to contact the carrier, communicating the ADA’s position that practitioners ignore these letters. However, it is important to send copies of the letter to the member advising you of the situation, the chair of the AGD’s Dental Practice Council, the AGD Director, Dental Benefit Programs and Dental Practice, and the individual at the state dental association who is responsible for dental care issues so the main offices of the AGD and the ADA can coordinate their responses. A sample letter follows.
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