MetLife Policies Illegal?

Dear Julia, I understand your question and your frustration. The reality with insurance that most patients (and dental offices) do not fully understand that contracts are written and agreed upon between the insurance company and the patient''s employer long before an individual patient has the need for reimbursement for a particular procedure. Therefore, if Met Life wishes to write a restriction into their plans that limit a certain procedure for whatever reason (this case being the limit of benefits for localized disease versus more generalized disease) that is within their right to do so, legally. What is not legal is for a dental office to provide the clinical procedure of Periodontal Maintenance, yet bill it to the insurance company as a Prophylaxis. The same would be true of providing a porcelain onlay on a tooth, but billing it to insurance as a resin in hopes that the insurance would reimburse some of the fee. As dental providers we are obligated to legally document and provide necessary treatment to the patient irrespective of the patient''s insurance benefits, or as in this case, lack thereof. It has been my experience that some insurance companies will downgrade a code internally and reimburse at a lower fee. For example, you may submit the D4910 and they may change the code to a D1110 and reimburse at the lower fee. Other insurance companies however, are not the least bit flexible in this regard and no benefit simply means no benefit. The patient at that point must become their own advocate and become the "squeaky wheel" in asking their Human Resources Department of their employer to increase Periodontal Maintenance benefits during the next contractual agreement between the employer and the insurance provider. After all, it is the patient''s benefit. You as the dental provider should be sympathetic with the patient, offer to supply whatever documentation might assist in receiving full benefits, but remain committed to submitting accurately what you have provided. It is helpful for you the dental team to remind all patients that dental insurance is ASSISTANCE, not FULL COVERAGE for everything they will need to maintain optimal dental health. This means throughout their lifetime they will pay out-of-pocket for some dental procedures. Attached, is a sample letter you may use on your own letterhead and customize for your patient that essentially requests full benefits for D4910 Periodontal Maintenance, yet also requests D1110 Prophylaxis reimbursement should the patient''s plan not provide for D4910. While this will not insure reimbursement, sometimes it is helpful just to show the patient you are willing to make a request on their behalf. LETTER TO INSURANCE CONSULTANT FOR PERIODONTAL MAINTENANCE -SAMPLE- Dear Dental Consultant: This patient has previously been treated non-surgically for periodontitis. Our practice follows guidelines established by the American Academy of Periodontology (AAP), and the American Dental Association (ADA) for on-going maintenance of patients following active periodontal therapy. Following, are excerpts from the AAP and ADA defining the difference between Periodontal Maintenance procedures and Prophylaxis. Our treatment reflects theses differences to keep disease in remission. We are asking you to provide full benefits for your client for Periodontal Maintenance at the frequency specified in their plan. Should their plan disallow Periodontal Maintenance, we are requesting that you assign their prophylaxis benefits toward this procedure. Please note, a dental examination by the doctor is NOT included in the definition of Periodontal Maintenance. Therefore, your client will receive a D0120 Periodic Oral Evaluation, or D0150 Comprehensive Oral Evaluation, or D0180 Comprehensive Periodontal Evaluation by the dentist, as indicated, and will be billed separately. Please reimburse accordingly. ADA Current Dental Terminology 2008-2009: D1110: Adult Prophylaxis Removal of plaque, calculus and stains from the tooth structures in the permanent and transitional dentition. It is intended to control local irritational factors. D4910: Periodontal Maintenance This procedure is instituted following periodontal therapy and continues at varying intervals for the life of the dentition or any implant replacements. It includes removal of the bacterial plaque and calculus from supragingival and subgingival regions, site specific scaling and root planing where indicated, and polishing the teeth. AAP Parameters of Care May 2000: Periodontal maintenance is started after completion of active periodontal therapy and continues at varying intervals for the life of the dentition, or its implant replacements. These procedures are performed at selected intervals to assist the periodontal patient in maintaining oral health. Our commitment to our patient, and your client, is to provide the highest standard of care available so that disease can be detected early, treated appropriately, and prevent further need for additional therapy, when possible. This has the potential to prevent incurring unnecessary expense in the future. Sincerely, John Smith, DDS, Inc.