"Consultation fee" for root canal covered on dental insurance?

[yorkriver1]

Looking at the evidence of coverage on the plan, it only addresses 2 exams a year, with one optional code for "problem focused". The endodontist says the dental plan won't cover the fee.
My thoughts are, maybe this is payback for dental network discounted rates.

 

[somarco]

If the dental plan requires pre-authorization for major work it MIGHT pay for a 2nd opinion . . . but I doubt it.

If the patient needs the work he/she should be willing to pay OOP for a 2nd.

Or wait until Prez Bernie makes everything free.

 

[LostDollar]

Looking at the evidence of coverage on the plan, it only addresses 2 exams a year, with one optional code for "problem focused". The endodontist says the dental plan won't cover the fee.
My thoughts are, maybe this is payback for dental network discounted rates.

An evaluation code sequence I experienced:

April Dentist B. D0120. 3 fillings recommended. I decided I did not want Dentist B doing the fillings. (In retrospect it is possible that may have been a mistake.) Instead of going immediately for a second opinion, I decided to wait for my second evaluation of the year.

August Dentist C. A filling fell out. D0220 xray for specific tooth. D0140 limited oral examination. (Dentist C also required some previous xrays from files at Dentist B office.)

November Dentist C. New Patient D0150 and D0274.

Dentist B and C accepted my insurance. Insurance adjusted D0120, D0140 and D0150 to network amounts and paid in full under preventive benefits.

I don't know if the insurance would have accepted D0140 from a second opinion dentist in the same time frame as D0120 was paid, and still left the patient with a second coverage for D0120 or D0150 later in the year, but it might be worth discussing with your client's insurance company.

 

[yorkriver1]

If the dental plan requires pre-authorization for major work it MIGHT pay for a 2nd opinion . . . but I doubt it.

If the patient needs the work he/she should be willing to pay OOP for a 2nd.

Or wait until Prez Bernie makes everything free.

I know. This client is expecting a lot from the coverage, mainly was mad for being blindsided by the fee and the dentist in network when plan was written had dropped out and the only other endodontist is 20 miles away. But, won't change to a richer plan with more dentists because it's part of an MAPD and her PCP isn't in network with UHC, who has really awesome dental benefits and network. I am going to let client cool down and realize "You can't always get what you want", to quote the rock philosopher Mick Jagger

 

[yorkriver1]

LD, you may have a point. I may call the dental office to ask if they can fit a code in there, the issue being the plan says only 2 exams a year, so if coded for this issue, client could miss out on what goes with a regular cleaning/exam.

 

[LostDollar]

I believe the hygienist cleaning is a separate billing code so I would guess someone could have that done without the accompanying "dentist eyeballing your teeth" exam if they wanted. again something to confirm with the specific dentist's office and suitability of that approach would depend on the patient's overall dental health.

 

[somarco]

I am going to let client cool down and realize "You can't always get what you want", to quote the rock philosopher Mick Jagger

I play that song quite often for clients and prospects . . .

 

[somarco]

I may call the dental office to ask if they can fit a code in there,

I would never ask a carrier or provider if a claim was covered. Let the client handle that part of it. If the claim is denied it's on them, not you.

FWIW I doubt the provider will know either, and if they are smart, they won't tell the patient it is covered.

 

[yorkriver1]

I would never ask a carrier or provider if a claim was covered. Let the client handle that part of it. If the claim is denied it's on them, not you.

FWIW I doubt the provider will know either, and if they are smart, they won't tell the patient it is covered.

That's what they did. Apparently not too worried if the person liked it or not. Biz good for endodontists.