Navigating dental billing can sometimes feel like exploring uncharted territory for even the most seasoned professional, especially with the prevalence of misconceptions circulating on social media. Let’s debunk 3 of the most common myths and shed light on the actual rules and procedures.
3 Revenue Costing Myths:
- Cigna never pays core buildups.
- You cannot appeal timely filing denials
- You cannot accept insurance payments that exceed PPO allowed amounts
Let’s break these down:
Myth 1: Cigna never pays CBUS - you have to write them off.
Reality: While it's true that some insurance companies may have specific policies regarding certain procedures, blanket statements like "Cigna never pays core build ups" are often inaccurate. Each case should be evaluated individually, and it's crucial to understand the terms outlined in your contract with Cigna.
“How do I get Cigna to pay for a core build up then?”
Call in the seat date of the crown! It is THAT simple. If you are an office that utilizes CAD/CAM technology - state this in your clinical notes, attach them to the claim, and double down by putting a note in the remarks that this was a same day crown, and the seat date is the same day as the prep date.
Myth 2: You cannot appeal timely filing denials, and these claims must be written off.
Reality: Timely filing denials occur when claims are not submitted within the designated timeframe outlined by the insurance company. Much of the time, the claim was submitted within the timeframe, and unfortunately the insurance company does not have it on file. With timely filing letters or images of the correct area from your clearinghouse submission reports, you can appeal these denials and potentially overturn them. Do you have a hopeless feeling due to a back up of timely filing denied claims that you don’t want to write off? We can help!
Myth 3: You cannot accept insurance payments that exceed PPO allowed amounts
Reality: Accepting payments above PPO fees can be permissible under certain circumstances, such as when there is coordination of benefits (COB) with another insurance plan or when the total fees charged do not exceed the usual, customary, and reasonable (UCR) amount
Example: Your office charged $120 for a prophylaxis. This fee (your UCR) is on the explanation of benefits. Insurance 1 (primary) is PPO and you are in network, and they paid their allowed amount of $70. Insurance 2 (secondary) is also PPO, and their allowed amount is $85. They paid $50 - the remainder of the difference between UCR, and what primary paid.
While secondary does not always coordinate this way, know that when they do, and UCR is NOT exceeded, the office may retain the total paid up to UCR.
Understanding the nuances of dental billing is essential for maintaining compliance and maximizing revenue for your practice. By dispelling common myths and staying informed with Wisdom, you can navigate the billing process with confidence and ensure the financial health of your practice.
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