Oral Pathology Puzzler: Do You See What I See?

a. Down-coding with the EOB stating to write off the difference. Let them know the new Utah Law allows them to still down-code, but they can not force you to write off the down-coded portion, nor should the EOB allude to such. b. Bundling and the EOB stating you have to bundle your procedures and write them off by including them. Build-ups with crowns, bitewing x-rays and panograph to a full-mouth series, diagnostic codes with a limited exam are just a few where you no longer have to write them off. c. The verbiage of a. and b. above needs to be corrected on the

EOB.

Step Four: Often times, the insurance company will not change the EOB. Is this right? No. However, the goal of the call is to enforce the law and get the representative to agree that they are wrong/ misinformed, and to correct the issue with you and your patient. 4. Your EOBs in the future will likely be wrong as well. 5. Our office will take any concerns you have seriously and follow up on them because WE care about you and your oral healthcare.

Let me teach all of you what we teach during our Front Office/ Office Manager training here at My Practice My Business: “Do NOT fear the beast”. Remember, the insurance companies have rules and regulations they need to follow. They cannot break the law or come between the doctor/patient relationship. They cannot “kick you out of the network” if you simply remind them that they are not above the law or if you file a complaint with the Utah State Insurance Commission. So many offices do not understand contractual law and state law and all the ways we have to increase net revenue. We’re more protected than you think.

Step Five: If a dental insurance company instructs you to “APPEAL” the charges with a narrative, and other such timewasting protocols, you should: a. Tell them you DO NOT need to “APPEAL” the charges,

THEY need to forward it for REPROCESSING with a note referencing the new Utah Dental Law, “Network Leasing,

Down-coding, and Bundling Protections” Law b. Let them know they have 30 days to process. c. If they try to state they, the dental insurance company, are determining “GENERALLY ACCEPTED PRACTICE

STANDARDS” regarding the claim, let them know that

“generally accepted practice standards” do not reflect “their views” in Utah. Those are, and have been, determined by the “licensed dentists” in our state, and tell them that if they do not change it, you will be filing a complaint with the

Utah State Insurance Commission. Tracy Thorup CEO, My Practice My Business www.mypracticemybusiness.com

PRACTICE

ORAL PATHOLOGY PUZZLER: DO YOU SEE WHAT I SEE?

Step Six: Thank them for their help, GET A REFERENCE NUMBER AND THEIR NAME, and ask when you can expect the outstanding claim to be reprocessed and fixed, and then YOU follow up on it. Even better: try to get them to call the patient and apologize for the misleading EOB. Have I had them do it before? Absolutely. And I loved every minute of it.

Which of the following represents the best diagnosis for the radioraphic findings in the anterior mandible? Oral Pathology Puzzler: Do you see what I see? a) Periapical cemento-osseous dysplasia b) Periapical granulomas Which of the following represents the best diagnosis for the radioraphic findings in the anterior mandible? a) Periapical cemento-osseous dysplasia c) Odontogenic keratocystsb) Periapical granulomas d) Lateral Periodontal Cystc) Odontogenic keratocysts d) Lateral Periodontal Cyst

Step Seven: Now, to address that wonderful patient of yours. Call them back, give them the reference number and name of the agent you spoke to, and tell them that it was confirmed that the EOB was incorrect and any balance due is their responsibility. I often follow up with, “I’m so glad that you were comfortable enough with us to voice your concerns. As I mentioned before, this is an issue that happens often with your insurance company, and unfortunately, we expect the issue to continue to occur with them. I’m sorry that your insurance company lied to you, but please know that we will continue to be transparent with you.” Why do I do this? To re-establish control. By following the above steps, I’m telling the patient quite a bit with that conversation: 1. Don’t tell me how to do my job. 2. I know the tricks that those insurance companies play. 3. Your insurance company will do anything to save themselves money and make me look like a “bad guy”.