Thursday, May 14, 2015

Sjogren's Syndrome Foundation Education Sheet: Insurance Reimbursement Tips for Dental Care

The SSF Sjogren's Quarterly Spring 2015 issue contains an excellent new Patient Education Sheet. To see other SSF Patient Education Sheets, check my left sidebar using a non-mobile device, or visit the SSF site here.

Patient Education Sheet
Insurance Reimbursement Tips for Dental Care

Ever since dentistry split from medicine, insurers have looked at dentistry as being sole confined to the mouth. Because Sjogren's is a systemic disease that affects the mouth, patients and their professional caregivers often have faced extreme frustration in obtaining reimbursement for care. This becomes even more difficult when trying to obtain reimbursement for care under regular medical insurance as compared to dental insurance. 

Basic Dental Care Reimbursement Tips for Any Kind of Insurance
  • See tips for reimbursement for medical care in SSF Patient Education Sheets on Health Insurance Tips Parts 1 and 2. Many of these are relevant for obtaining reimbursement for any kind of healthcare.
  • Read your insurance policies carefully. Know what they will cover, will not cover, and what is not explicitly stated. The latter can provide a window for pushing for coverage. Be prepared to prove that your treatment qualifies for coverage under your plan.
  • Always appeal a denial!
  • If denied, find out what led to the insurer's decision, and keep a careful paper trail. Mail your appeal certified with return receipt to document that your appeal was mailed within the specified time frame.
  • The appeal claim address might be different from the submission address, so check carefully.
  • In all corresponding documents, include: date, claim number, date of service, subscriber number, group or policy number, amount of charge, and dental provider name. In addition, describe the denial, why you are writing, and what you are requesting, Ideally this initial letter should be clear and concise. Templates are available on line to help with wording if you need to do the appeal yourself.
  • Do not send original radiographs, as they might get lost.
  • Provide a cost-benefit analysis when possible - For example: the cost of having more frequent dental check-ups and cleanings when someone has a dry mouth can save the insurance company the much higher cost of obtaining fillings, crowns and/or implants.
  • Remember that you are the client and pay for your insurance. Don't be afraid to place the insurance company on the defensive and make it clear that the company must justify its refusal to cover what should be deemed medically-necessary care. Stress the medical repercussions if you do not get the care you need and the potential negligence on the part of the insurance company if you do not get that care.
  • A common insurance phrase when considering reimbursement charges is "usual, customary, and reasonable" or "UCR." This can be extended to include the care required for a Sjogren's patient. The SSF Clinical Practice Guidelines for Oral Care and Management can be cited to prove usual and customary care.
  • Provide a Letter of Medical Necessity. A Sample Letter of Medical Necessity for dental treatment can be found on the SSF website under "Brochures and Resource Sheets."
  • Include two or more articles from respected dental or medical journals backing your claim of medical necessity.
  • Refer to the SSF website and the SSF brochure on Sjogren's and Dry Mouth as an authoritative source of medical information on Sjogren's. 
  • If you do not already have dental insurance, consider obtaining it.
  • Be persistent but friendly, and document all of your interactions.

For more information on Sjogren's, contact the Sjogren's Syndrome Foundation at:
6707 Democracy Blvd, Suite 325, Bethesda, MD 20817 
800-475-6473   ssf@sjogren'

Clinicians: Please make multiple copies of this Patient Education Sheet and distribute to your patients. 

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