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What is the most ridiculous, confusing, most denied procedure dentists bill insurance for?

Posted on October 17, 2015 at 11:30 AM

Q: What is the most ridiculous, confusing, most denied procedure dentists bill insurance for?

A: The simple core buildup has been redefined by both the insurance companies and the ADA in the past 2 years. Somehow, over the years, insurance companies have decided that the core build-up is part of a crown procedure and thus have avoided paying us for it. Delta Dental, Metlife, Guardian, Pomco all guilty of selling a plan to employers with the clause of core-crown bundling. How they got away with this bundling I have no idea. The fact is that not only do they not pay for it, but if you are a provider, by contract they don't let you charge the patient for it either! Another frequent denial is that “the x-rays reveal that THERE IS enough tooth structure present to support an indirect restoration without the core”! We have seen this denial with replacement of an existing crown. Now how on earth can the examiner see that there is enough tooth structure from an x-ray that shows existing crown blocking everything. Isn’t this crazy?.

Anyway, in response to this the ADA (in their 2014 dental codes update) came out with a new code D2949 (restorative foundation for an indirect restoration) to redefine clinically what we are doing. Now we need to identify whether we did D2949 (placement of restorative material to yield a more ideal form, including elimination of undercuts) or did D2950 (refers to building up of coronal structure when there is insufficient retention for a separate extra-coronal restorative procedure. A core buildup is not a liner to eliminate any undercut, box form, or concave irregularity in a preparation).

Let me tell you the implications here. First of all, often, the insurance companies do not cover new codes for at least 5 years. So if you are doing D2949 you need to charge the patient sicne there will not be any help from insurance there. By creating 2 codes our patients now have 50% chance of getting help from their insurance. The good old core buildup that was meant to improve the retention, to yield a more ideal form, to rebuild missing tooth structure, or to support the tooth after root canal procedure now is categorized pretty much by how much material you used and where. We all know that many cores are done to yield a more ideal form, including elimination of undercuts. Seriously? Why the difference, why did ADA do this to us? A core is a core…functions as a support to a crown no matter where or how much the dentin is rebuild or filled-in to eliminate undercuts. We get annoyed when submitting cores because often we get funky denials. There are way too many plan specific insurance clauses which in the end DO NOT pay for the core build-up. Especially in provider practices

Categories: clinical dentistry, dental insurance

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3 Comments

Reply ABS
6:51 AM on December 11, 2018 
Many people mistakenly believe when they go to their dentist who is contracted with an insurance company, the dentist represents the insurance company. Not True. Your dentist receives a fee schedule, the insurance company?s fee schedule, at the time they contract.

ABS - www.atlantabasedsystems.com
Reply StepNem
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