Unlock the Secret to Maximizing Dental Reimbursements
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Understanding how insurance companies bundle certain procedures is crucial for maximizing reimbursements and ensuring patients receive the best care. This issue of The Dental Decoder focuses on the importance of coding treatment based on what the doctor performs, not on how insurance pays.
Code Bundling: What You Need to Know
Insurance providers frequently bundle specific dental procedures, which can impact how claims are reimbursed. This can create challenges for both treatment planning and patient communication. Implementing a structured approach can help mitigate these issues and ensure accurate billing.
Understanding Bundled Procedure Codes
Bundling occurs when multiple procedures are combined into a single charge, which can reduce the patient’s covered benefits. When a provider signs a contract with an insurance company, they agree to follow the plan’s policies, which are often outlined in provider manuals. Whether or not a dentist can bill the patient for bundled procedures depends on their network status with the insurance carrier. The Explanation of Benefits (EOB) will specify what the patient owes out-of-pocket. For out-of-network providers, full fees for all submitted procedures may be billed but remember a dentist should always code based on the procedures they actually performed.
Examples of Code Bundling in Dental Treatment
Crown with Core Buildup
Some insurance carriers bundle D2950 (core buildup) with the crown, meaning they will not reimburse it separately.
However, with proper documentation proving that the buildup was medically necessary and separate from the crown prep, many claims can be successfully reimbursed.
ADA Article reviewing core buildups: https://www.ada.org/resources/practice/dental-insurance/cdt-code-d2950
Gingivectomy (D4212) with Crown Prep
Aetna PPO: D4212 is reimbursable when performed with crown preps.
Delta Dental PPO: Will bundle it and not pay separately with crown prep BUT will pay with proper documentation with crown re-cement.
Solution: Always code based on the procedures performed. If bundling occurs, adjust the patient’s ledger according to the Explanation of Benefits (EOB).
Best Practices for Treatment Planning & Insurance Coding
Code Based on Services Rendered: Always code procedures based on what was performed, not on how insurance companies might bundle or reimburse those services. This practice ensures compliance and ethical billing.
Educate Patients: Inform patients that treatment plans are developed based on clinical needs, and insurance benefits are estimates. Clarify that final financial responsibility may differ once the insurance processes the claim.
Streamline Systems: Given the variability in insurance policies, it's beneficial to have a streamlined treatment planning system. This approach reduces the burden on administrative staff and ensures consistency in patient communication.
Proper Documentation: Maintain thorough documentation and provide detailed narratives & applicable attachments when submitting claims. Proper documentation can support the necessity of procedures and may prevent bundling or downcoding by insurers. Remember to bill all x-rays and photos needed for the procedure to the insurance for reimbursement.
Valuable Resources for Dentists
If a claim is improperly processed, providers should file a written appeal with the insurance company. The American Dental Association (ADA) also offers a Contract Analysis Service, which allows members to submit unsigned contracts to their local or state dental societies. These contracts are then reviewed to provide a clear, non-legal explanation of the terms. While the service does not offer legal advice, it helps providers understand their agreements before signing.
To access an Appeal template to use click here.
For additional guidance and ready-to-use resources on managing dental insurance challenges, visit ADA.org/dentalinsurance.
Exclusive Expert Resource & Tip
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Just as this strategy has been proven effective, we have numerous other ethical and legitimate techniques that help practices increase revenue by ensuring they get paid for the services they provide.
Make the smart choice for your practice—invest in an expert outsourced billing, and you’ll immediately see a boost in production simply by coding treatments correctly and utilizing the documentation guides provided by an expert. We take pride in helping dental offices thrive and ensuring that every service performed is reimbursed appropriately.
Enjoy this free resource, and don’t hesitate to reach out for a complimentary consultation—we’d be delighted to assist you!
How Arevalo Elite Services Can Assist
Our expertise in dental billing ensures that procedures, even those typically bundled by insurance companies, are properly documented and reimbursed. We have successfully secured payments for treatments such as gingivectomys performed with crowns and buildups through strategic documentation and appeals.
Looking for Support? Schedule a consultation with us to enhance your billing processes and optimize reimbursements.
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Stay informed, remain compliant, and maximize your reimbursements!
