Call Center Information - Be Wary!

Back

I read Insurance Solutions from cover to cover to be up to date on current insurance situations. Your January/February 2010 article about insurance call centers not being aware of their own revised policies made me want to share this experience with your readers.

I had an interesting situation with Delta Dental of Missouri with regard to a case involving implant placement and restoration. The patient is covered through her employer, Enterprise Car Rentals.

Upon predetermination for an implant (D6010) replacing tooth #19, we were told that there was no implant coverage. However, we were told that the abutment supported crown (D6058) would be covered but with payment under code D6245 (porcelain/ceramic pontic). Once the implant was placed in October 2009, I submitted the claim for D6010 to Delta Dental for information only, understanding that there would be no coverage.

We received benefits for D6750 (porcelain fused to high noble retainer crown) for teeth #39 and #40 (not a typo!) with an allowed amount of $1975 (the amount we charged for the implant), and a payment amount of $636.80. When I called Delta Dental to inquire about the payment, I was told that I was given an alternate benefit of a bridge but that the crown on the implant would not be covered.

Because of the money the patient had set aside in her flex plan, she wanted the insurance benefit to be allocated for 2010, not 2009. I explained this to the phone rep, and she said to send the funds back to allow benefit for the restoration on the implant this year. I thought this was strange. After several phone calls, I realized that Delta Dental’s phone reps did not understand the alternate benefit for an implant on this policy.

The implant crown was placed in January 2010. When the patient contacted Delta Dental a call center rep told the patient that our office “blew it” (the rep’s words), because we said the implant had been placed. In my first letter to Delta Dental in November 2009, I mentioned twice in the letter that the implant was placed on October 14, 2009, so I don’t understand why she would have told the patient that.

I wrote a second detailed letter to Delta Dental with a copy of all correspondence (initial letter, PreDs, and x-rays) to explain the confusion. I received a phone call last week from a supervisor who, after reading my letter, listened to every phone call regarding the claims. The supervisor sincerely apologized for the lack of information and amount of confusion given by the Delta Dental phone reps. She said she found it difficult to understand anything that was said by the phone reps and the misinformation was uncalled for. She was processing the original claim for the implant and the second claim for the crown herself and commended me on the thoroughness of my claims and documentation. I also commended her for her phone call and apology, something I have never received in my 30 years of dental experience.

So, Delta Dental of Missouri’s Enterprise Rental Car plan gives an alternate benefit of a bridge but does not clarify this in its predeterminations. I hope other dental staff members do not give up and believe procedures are not covered based on what they hear from call center reps. It pays to be a squeaky wheel and to bill EVERYTHING you do to the benefit plan. I can’t stress enough the importance of reading the EOBs to see why something is denied and taking the time to question the denial. - Diane (Sant Clarita, CA)

INSURANCE SOLUTIONS EDITOR'S RESPONSE

Thank you for taking the time to share your experience with our readers, Diane. I am sure many have had similar experiences. It is a good reminder that benefit information obtained from dental carriers’ call centers may not be accurate.

So, what can everyone take away from Diane’s experience?

Never completely rely on information obtained from a dental carrier’s call center. Whenever possible, try to obtain benefit information from the patient’s benefit booklet, carrier’s website, or other internet portal (e.g., Emdeon’s DPS).
Keep a record of your call. Document the date and time of your call, who you spoke to, and exactly what was said, using quotation marks, whenever possible.
Bill every procedure, whether you think it will be covered or not. By doing so, you provide the carrier with treatment history that may be a prerequisite to coverage for future procedures. You may find that the patient’s benefits changed since you last checked, and/or that the patient qualifies for benefits set aside in a COB reserve account (see July/August issue, page 9).
Watch EOBs carefully and be prepared to follow up when benefits are reduced or denied. If you do not have the time to follow up on denied claims, suggest that your patient contact his/her carrier directly or notify his/her Employee Benefits Manager of the problem.