Apparently, insurance companies are violating their third party payer agreements to reduce benefits to patients. In order to use the ADA’s intellectual property, i.e. dental procedure codes, the insurance companies have to agree not to change the code’s nomenclature and description. However, what is happening is your insurance companies are redefining submitted procedural codes with combined codes that pay you less benefit than you are entitled to. This is called code bundling, which is designed by your insurance provider to reduce your benefits.
HIPAA requires that the procedure code reported on a claim be for effective service rendered on the date of submission. Unfortunately, there is no effective way for dentists and their patients to enforce this requirement and the result is a misunderstanding created by insurance companies that suggests ‘it’s your dentist’s fault’.
The solution is patient push back for the coverage you’re entitled to. Patients need to question, if not challenge the benefits they have paid for but have been denied. And patients need to recognize that the contractual relationship is between you and your insurance provider, not your dentist and your insurance provider.
Hopefully, this is a little helpful in understanding the difficulties of receiving your full insurance benefits. If we can answer any of your concerns, please feel free to contact us.
Novy Scheinfeld, DDS, PC
290 Carpenter Drive, 200B
Atlanta (Sandy Springs), GA 30328
Thank you for all your referrals. We truly appreciate them.
Information included is not dental or medical advice. For your specific information
be sure to consult your dentist.
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