Let’s Talk About Crown & Bridge

When a patient needs a crown, inlay, etc., it is critical to have diagnostic pre-op x-rays, photos and narratives. This is where your intraoral camera is worth its weight in gold. It is pretty easy for a plan to determine a benefit when the x-ray shows a tooth that is almost all filling and very little tooth structure. It is more difficult (and usually a reason for denial or delay) when the x-ray shows only a small occlusal or two surface filling. What the plan doesn’t see is the fact that the filling is quite large in circumference or that possibly the large old amalgam has several cracks in it, the margins are washed out and leaking and the entire buccal cusp is undermined. You can of course document this in your narrative, (most doctors & assistants don’t document that thoroughly) but the benefit determination is at the discretion of the claims processor. Photo’s don’t lie and are difficult to dispute.

If your claim is denied, you will have to go through all the trouble of filing an appeal and requesting a review by a panel dentist. This could cause a delay of four to eight weeks on top of the time it has already been since you sent in the first claim. You could of course, bill the patient, but most offices will hold out on that during appeal.

If a claim is denied for lack of diagnostics, in what would otherwise be an easy determination, is that the patient’s fault? You will again be put in the avoidable position of having an angry patient and a higher than necessary outstanding accounts receivable. If this is a replacement crown with open margins, or re-decay, then I would advise asking the doctor if you can take a diagnostic bitewing (no overlaps, no elongations or foreshortenings. The margins must be crisp and clear) in addition to the required PA. Since most leaks or open margins are on interproximal surfaces, the bitewing will demonstrate this better than the PA and reduce an excuse by the plan to deny your claim. If there is an open margin or leakage on a buccal or lingual, then the use of your intraoral camera could substantiate your diagnosis and claim and you should get paid without any delays.

There are three common classifications of metals when referring to crowns and bridges.

High Noble D2790 has at least 40% gold content. Noble D2792 has at least 25% gold content and Predominantly Base Metal D2791 has less than 25% gold content. Most plan benefits allow for Noble metal.

It is important to know what types of metals your lab is using in order to bill properly. Many overseas labs use a base metal in order to keep costs down. If your lab is using high noble, you will be paying higher lab fees, therefore you should document and bill accordingly. Keep in mind that in most circumstances, the patient will have a higher co pay due to the upgrade in metals. If the dentist bills for high noble and the patient is receiving a noble metal crown, or if you are billing for noble metal and your lab uses base metal, the patient isn’t actually getting what they are billed for. It can then be considered insurance fraud, even if unintentional, so you need to be very careful in this area. The plan may also have exclusions for porcelain on molars. In that case, the patient’s co pays could be higher. It is extremely important to have a good relationship with your lab tech so the lines of communication are always open. A good lab tech will understand the dentist’s needs and always deliver a quality product.

Let’s look at this case:

6-11 pre – auth was sent for D6240 Pontic Porc to High Noble & D6750 Abutment High Noble. The plan re-assigned the codes & approved for D6241 Pontic Porc to Base Metal & D6751 Abut Porc to Base Metal

When the pre auth came back, NO ONE noticed that the codes were re-assigned to a lesser benefit OR that even though it was “approved” the patient was well over his max. No one advised the patient what his financial responsibility would be.

Treatment done…No consent form, no financial arrangements. NO ONE noticed (or spoke up) that the patient and the Dr. changed the treatment plan in the chair to an all ceramic bridge. The pre auth was sent for payment, the insurance paid the claim and the patient later received a bill from the office for several thousand dollars on top of what he had already paid. What do you think happened next? The patient filed a grievance with his insurance company and the dental board for fraud. The Dr. was held responsible. The insurance company performed an audit and the Dr. was ordered to re-imburse the insurance company and the patient. That patient got a high end beautiful 6 unit bridge for free.

That was a pretty pricy error. Let’s take a look at some things that could have been done to avoid this.

1. Have a dedicated person (and a backup person) that is in charge of following up on pre- authorizations. They must read them carefully and understand them completely. They must call or see the patient to thoroughly explain the patient’s benefit, and make financial arrangements. It is crucial that this conversation take place before the appointment date. This gives the patient a chance to arrange financing, or if they need to reschedule, gives you time to fill that 3 hour gap in the schedule.

2. What role did the chairside play? The consent form must be signed after the patient and the dentist have reviewed the case. The case should have been discussed in the morning huddle, so if the treatment plan is different from what was done today, that should be apparent and the assistant should have brought it to the immediate attention of the insurance coordinator.

3. Who is entering the treatment? Is there a policy or procedure in place that ensures everything matches and correct codes are put on final claim?

It is crucial that the narratives are complete, conversations are documented, and all treatment verified against the treatment plan. This will make a smoother and more profitable day, happier patients, and will reduce your risk of audits, grievances, and possible legal action.

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