Weekly Insurance Tip: Why your buildups are getting bundled/denied and how to get them paid

[music] >> Welcome to the navigating dental insurance podcast, where we don't take from insurance [music] companies. Here are your hosts, Mr. Jordan Comstock and Mr. Ben Tuinei. >> [music] >> Welcome to another exciting episode of the navigating dental insurance podcast. I'm one of your co-hosts, I'm Ben Tuinei. Jordan Comstock is taking a leave of absence during these early summer months as he's spending time with family. So, uh this is our weekly episode where we talk about quick insurance tips. And today, of course, as you can

see in the topic or the title of this episode is how I get these insurance companies to stop denying buildups. And it's not just buildups, it's other things, but we want to highlight buildups simply because I I met with a Delta Dental Dental Director. I won't mention his name or the state that he represents. And he had mentioned to me in a meeting privately, off the record, um that Delta Dental and every insurance company, the two areas of increased auto [snorts] denials are going to be

buildups, number one, and number two, perio. Today, we want to talk about the buildups and those items [snorts] getting denied on a on a on a frequent basis or even bundled. So, here we have Tessena. Welcome back, Tessena. It's great to have you again. >> Hi, thanks for having me. >> Absolutely. We love picking your brain on these things. So, so when it comes to these buildups, Tessena, like why why are they like it's a legitimate thing, right? You can't retain a crown without a buildup.

>> Right. >> And yet insurance companies are denying them indicating that they're not necessary or there's not not sufficient evidence indicating that the buildups are should be performed or covered. And then number two, they're bundling them with the crown, right? Where there's no reimbursement. What tips do you have to help practices either unbundle or get these buildups these denials overturned? >> Yeah, definitely. That is a huge question I get asked all of the time, by the way. And all of the offices that I go into

and their claims issues they're like, but all of our buildups get denied, right? It's a very common problem. And you hit the nail on the head, right? With like it's just an automatic denial. They're not even looking at any documentation. They're not processing any of that. Nobody's investigating it. It's just flagged for an automatic denial. So, that's the number one thing. The second thing that I would say is the most important thing is on that initial claim, this is step one. On the very initial claim,

you have to reference that more than 50% of tooth structure was lost and that the the buildup was required due to that reason. That is the the the save all, right? So, that a lot of times that'll get that buildup processed right away, but not always because it is flagged for an automatic denial. But as long as you have that in that remark section of that claim going out, it'll be so much easier to get that reprocessed for correct payment cuz you'll be able to reference

that you already gave that to them that first time around and that they processed it incorrectly. So, again, this will come later on as we start talking about training the insurance companies to to fall in line with what you're doing and this is one of those steps is you fill you you make sure you have the proper wording that first time around on that crown on that claim and then if they deny it, then what you're going to do is call them up or resend the

claim saying, I already gave you the information needed to process this claim. It is a separate procedure per the ADA and is not available for bundling or and is not included in the service, right? It's a separate fee and should be paid as such and tell them that you want them to reprocess the claim immediately for payment to avoid a complaint to the insurance commissioner. So again, we're always referencing the insurance commissioner, but it's not just a threat, you guys. We're going to use it. >>

Yeah. [laughter] Yeah, you got to follow through with your threat. >> Yeah, you follow through with that promise and I promise you they'll back off. Um, but it doesn't usually ever make it that far. Once you reference to them that you've already provided the information again is more than 50% of tooth structure has been lost. That's what the qualification is to get that build-up covered as a separate procedure. So as long as you have proof of that, whether it's an x-ray, but your words, your narrative

is key on that because they're not actually allowed to diagnose any treatment based off of any x-rays that you have. They have to take your word for it. So your word is your bond, your word is gold. You just make sure you tell them that um, it has that uh, that required key I call it key terms, key phrases. You have that key phrase in there and then you have all the power you need. >> Mhm, very good. What about insurance carriers that bundle? Like they'll

you submit that information, they'll continue to bundle it, right? Are there some insurance carriers that have preferences like their own policies that say we want you to report the seat date or we want you to to report the the build-up on the the prep date and the crown on the seat date. Do you run into those issues with insurance companies having specific policies on bundling? >> Occasionally and what they're doing is just in efforts to delay the the claim for payment. They know they have to

pay it and none of that information actually has anything to do with anything. So this is again where sometimes we have to get the insurance commissioner involved, but sometimes the threat is enough. Your appeals and we'll get into this more as well in the future, so I promise there's more details to come, but um, your appeal is not like, "Please pay this claim here's more information here's more documentation your appeal is I already gave you everything that you need pay up or I'll report you. >>

[laughter] >> It's kind of like it's kind of like having a neighbor that's consistently well they don't have like in a state where where marijuana is just illegal they don't have medical marijuana right but they're always smoking weed next door right and and not that you want to be a snitch or anything I don't >> Right. >> but but the example is is you you go to them and say look this is affecting our health you know we don't we don't do that and if you

continue to do that we're going to have no choice but to let the authorities know. You know you quickly see behavior change when people companies or entities are faced with dealing with law enforcement that's coming to enforce an issue that's that you're doing that's illegal right? >> Yeah. >> And surprisingly well I I guess >> [snorts] >> I guess it is a surprise but insurance companies the 800 pound gorilla right where they they just say well we're a nationwide company there's nothing you can do you're

just one small person with one small office and yet when when one person or one practice gets the insurance commissioner involved or appeals in a way where there's >> Yeah. >> you know in the political and and the um um law enforcement arena or the lawyer arena saying when you appeal with teeth right where where where you have aggressive well an aggressive argument and a solid backup of law enforcement or government officials to enforce laws insurance companies tend to be to change their behavior. >> Yeah.

>> 100% so they're banking solely on first that automatic denial that you won't do anything about it and you'll just accept it. The second thing they're banking on is that you won't appeal it or know how to properly appeal it. The third thing they're banking on is that like you won't fight for it cuz it's like 50 bucks or something. So, offices do that. The problem is is that you're not arguing it. You're saying to me, "When I come in there, there how do we get

them to stop denying the buildups?" Have you fought it? Have you reported it? Have you done these things? No, it's not worth the fight. It costs us more money to fight it than what we would get paid. But, one or two of those fights and then they won't deny them anymore. They'll back off of you. So, it is worth the money. >> It is worth the fight and the time because then you'll get less of those denials. >> You bring up a good point. So, for,

you know, spending an example spending $50 in payroll to get a $20 treatment paid [music] for, a lot of practices >> [snorts] >> ignore that, right? They're like, "Oh, it's just 20 bucks." But, when you look at buildups, if all your buildups go unpaid and denied, for the average Well, for you know, average practices, single doctor practices in the United States, buildups represent 70 to $110,000 a year in revenue, in actual revenue. >> Yeah. >> So, to say that we're not going to we're just not

it's just it's not worth the time, right? I don't know about you, but $70,000 to $110,000 a year, that's a lot of money. >> Right. >> that's life-changing income for people, for most people in the world, you know, but let alone here in the United States for business, that is significant income that you can add to your bottom line. >> [music] >> Yeah. >> So, thanks for that advice, Tessina. I really appreciate it. Well, the listeners really appreciate it. And so, for those of you that

want to want to learn more about Tessina and, you know, her her skills and techniques, I know that she's going to be adding these episodes and a lot of the educational things that she does on her website, uh check her out at verusdental.com. Verus is spelled v e r u s dental.com. And of course, you can just click on that in the show notes to see what she's all about. So, Tessena, thank you again today for imparting your knowledge. It's always great to chat with you,

and we look forward to our next episode. >> Yeah. >> And to our listeners, we wish you all the very best of success throughout the week. >> [music] >> Take care, everybody. >> [music] [music]