Are you sick of denied claims? Listen to this!

[music] >> Welcome to the navigating dental insurance podcast, where we don't take from insurance [music] companies. Here your hosts, Mr. Jordan Comstock and Mr. Ben Tuinei. >> Welcome to another exciting episode of the navigating dental insurance podcast and the insurance entangled podcast. My name is Ben Tuinei and I'm one of the co-hosts on both of these podcasts. And as you know, we've sort of created these podcasts to help doctors that are in the thick of the mess of dealing with insurance [clears throat] these days. Uh

today, I have my good friend Tessina uh as a uh co-host with me today. Tessina, thanks for joining us again. >> Thanks for having me. >> Absolutely. It seems like the listeners want to hear from you more than anybody else. >> [laughter] >> So, we're well honor their request by continuing to have you kind of share and impart your knowledge. So, today, we we sort of are running into this issue of practices that are getting a consistent amount of denials on certain procedures. Uh last week,

we came across a situation for an endodontist in Louisville, Kentucky, but this is sort of a common story that you see across the country. Um he's an endodontist. He gets paid by insurance carriers on initial root canals, but there's one insurance carrier in particular and to avoid the the repeated cease and desist letters that we get from insurance companies, we won't mention their name. I really want to because it's like this is an insurance carrier that we really want to push back hard on. Y'all know

who it is. But this insurance carrier is there's coverage for retreats for this client, but they're well, for the patients that is. But they get denied 100% of the time, so the practice has to go through the appeal process to even get a retreat. And then, the insurance company still doesn't pay. They don't answer phones, they don't respond to uh repeated claim submissions. So, that's what we're going to talk about today, and I'm just going to let Tess and I I'm going to sort of guide

this discussion from the perspective of asking questions that the listeners are have on their mind. But, Tess and I are going to sort of explain and provide some education on how we want to go about these things. So, so with that situation, Tess, let's use that that endo example. Initial root canal's getting paid, retreats not. Um what would you recommend after after this practice now knows this is a pattern and it's not cool because it's happening all the time. Can you walk us through the very

first step that you would take to at least explore an appeal process for for something like this? >> Yes, definitely. So, first step always goes back to um like a good breakdown of benefits for me. Um not just asking if the service and this consideration it's a retreat. Um not just asking if it's covered, but what the exclusions and limitations are. They may have in their contract built in that they have an exclusion that if you do um on I always tell people on a rainy

day >> [laughter] >> if you do it on a rainy day, then it's not covered, but other than that we cover it. And that's their way of saying it's not covered, but we want to make you um honor the contracted rate. Because again, if it's technically a covered service being denied due to an exclusion or limitation, you're required to get it the contracted rate. So, this is their way of saying this is really not a covered service we want to pay for ever. Um so, we're

going to hide an exclusion in here. So, if you know about that ahead of time sometimes there are some things you can do to make sure you actually meet those requirements and you're not within that exclusion and limitation. Um otherwise, if that is um the only time that that procedure is done is within those exclusions and limitations, you know that they're not going to pay for it. And then you know to prepare the patient, and I tell my patients that they have an exclusion that this

retreat is not done on a rainy day. And guess what? It's raining today. [laughter] >> Got it. Yeah. So, follow-up question to that, Tess. Now, that's actually really good advice. Um I'm assuming you would perform this during the verification call, right? >> Yeah. Mhm. >> Okay. What specifically are you Like if for for endo, let's say it's a uh um endo, they do typical endo, right? Just root canals, retreat. Things in the endo category. What sort of questions would you be asking when you're either on

the phone or going on the portals to find benefit information? So, you said frequency, right? >> Uh-huh. Yeah. Frequency, but specifically exclusions and limitations. >> Okay. >> Um that is specifically what you want to ask for if you're on the phone with them. If you're on the website, look for the handbook, the dentist handbook, especially in regards to this insurance that we're not naming. >> [laughter] >> That shall remain nameless. That website always has a handbook. And for this insurance that we're not naming, there's a

different one for each state. So, make sure you're on the correct website for your state and using the correct dentist handbook. In that handbook, you can search that handbook for your retreat code or whatever code it is and find those hidden exclusions and limitations. When it's in the contract, we have very little wiggle room for using My next favorite spot would be the insurance commissioner. But before that, we have to find out what's written into their contract. And if it is abiding by their contract and

you have signed their contract as an in-network provider, you're agreeing to those exclusions. >> Got it. Got it. So, before we go to the insurance commissioner, I've heard from you in the past that going through this first step is important, right? In fact, um uh I heard from you that you have Well, the insurance commissioners want you to do at least one appeal. >> Yes. >> And if it gets denied, then you can go to the insurance commissioner, is that right? >> Yes. Uh-huh. So, it's

a fair request. The insurance commissioner is just asking us to do our work. >> Yeah. >> To do our side of it, make sure that we're following within those contract guidelines, and that we have um attempted to appeal it once. So, we've attempted to notify the insurance company of their diligent act that we believe is um you know, their um What is it? Not diligent. Their um What's my word, Ben? Their their wrongful denial. So, if we feel like they were wrongfully denying it, we do

need to bring it to their attention, say this is why we think this was wrong, and give them an opportunity to correct it. So, if they don't correct it, then we have grounds if we've already checked all the other boxes, now we have grounds for a complaint. >> Got it. And my apologies for not responding quickly with with the finding words there cuz I'm I'm still at 42.3% capacity with uh >> [clears throat] >> coming back from the flu. >> [laughter] >> That's okay. Usually, I'm

good with my words, but sometimes they're just gone. I'm like, where did my word go? >> [laughter] >> That's the same way. I But, I understand what you're saying here. So, that's good, you know, um yeah, the idea that, hey, you know, after all that you can do, then come to us. That's what the insurance commissioner is saying, right? Well, not after all you can do. It's like, you have to at least try once, right? You have to at least give us a tool to help

you and and and the denial for your first appeal would help the insurance commissioner. So, for those of you listening to that, don't get frustrated with that. That's that that's it's not very difficult to submit for an appeal. Um but, most practices, when they get a subsequent denial, they're appealing on their own again, and then again, and then again, until the insurance company says, "We're never going to pay for this." Right? And then they get the practice gives up. Um so, okay. Before we go to

the insurance commissioner on this particular matter, one question that has come up last year when one of the listeners presented the question surrounding this issue is So, if you see a pattern that these insurance companies are consistently design denying a certain treatment category that should be covered, um should should is it a good idea to to pre-op those? Would would a pre-op Okay. >> I'm not a big fan of pre-ops, um in general. I think that is asking permission to the insurance company to cover a

service rather than saying this is a covered service, a required treatment, and therefore it should be paid, right? So, a whole different tactic there. There are definitely some good situations to do a pre-op then. But, because you're seeing a recurring denial, that is not an indicator that that would need to be a pre-authorization. Um again, we're just showing them that we are accepting their denials and letting them run the game, run the show, and saying like, "Hey, we know that sometimes you don't like to cover

these. Is this going to be one of those times or not?" Instead of saying this is a covered service, we followed your guidelines, time to pay it. >> Yeah. Yeah. So, I'm going to I'm going to sort of um chime in on giving my my version of the same my version of the answer for the same question, should we do a pre-op? The listeners, I hope you appreciate this because Tessina and I have Our opinion on this is is is different, but it's for valid reasons.

And Tessina's Tessina's recommendation is actually correct. In my opinion, it is bulletproof correct. Don't do pre-authorizations if you know exactly how Tessina uses the insurance commissioner cuz when you go to the insurance commissioner route, which we'll talk about here in a second, you tend to find that the advocacy is so much more powerful than the pre-authorization route. Um now, let's talk about the pre-authorization route. So, there many practices that do this. And you'll see here why why Tesson is advising not to do this cuz her

way, in my opinion, is better. I'll concede to that. But, we do have a a lot of offices that don't have time to to to figure out the insurance commissioner route or call them, right? So, they're like, "Well, what other solutions can we do?" So, there have been some practices that have done pre-authorizations in California, that is. We'll start with the state of California. California, they do the pre-authorization, the claim gets denied, but the pre-auth says approved, right? It says it's been There are Well, it

says approved, this is how the claim would be processed, but this is not a guarantee of benefits. Of course, that's written so that if the patient has maxed out their benefits, it's not misleading to give them a pre-authorization that they're expecting to get covered when, in fact, they don't have benefits covered, right? But, in California, and to the best of my knowledge and talking to most of the state regulators, there's a law called the Knox-Keene and the Knox-Keene indicates that a pre-authorization is a pre-approval. So,

when Tesson mentioned that when you submit for a pre-authorization, it's almost it's almost like you're asking the insurance carrier for permission to do treatment. Um fortunately, the laws have changed. That statement that Tesson has said, for the most part, is an opportunity for insurance to be proactive to get prepared to deny a claim, right? >> [laughter] >> It That That could very well be cuz they're getting information from you beforehand, right? Before treatment is done. And I have seen that evidence that that sometimes has occurred.

Um but, because of that Knox-Keene, it it is starting to reverse the dynamic and the trend of pre-authorizations to where a prac- a lot of the listeners have said, "All I did was submit the pre-auth to the insurance carrier and then that kind of button things up in terms of them uh paying for the claim, but it took time. It took a lot longer than going the insurance commissioner route for that particular method to work." So, if you think about it, yeah, pre-authorizations are showing in

special states like California that have a law. They're showing to be effective, but it is so much more administration. It's a lot more administration than if you use Tessina's route, which let's dive into that right now, Tessina. Anything else you want to say about, you know, the pre-auth? So, it they do tend to help in not all states, certain states, but it it's just very, very much cumbersome in terms of administration. Your team members are >> Yeah. >> a lot more time doing doing that route.

Any any comments on that before we move on? >> Yeah, I'll tell you the other concern with that is that that approval, let's say you get a fee increase, and that approval was done before your fees were increased, if they pay on that pre-authorization, you're getting paid at the old lower rates, even though you've done them during the time of your increased rates. So, they will tie any old fees that they can to that. So, it can backfire a little bit, however, but at least you

got payments. Some offices are like, "Hey, I got payment." You know, I'm just happy to get anything. >> Yeah. >> But, that So, there is a time and a place for it. I have seen that if they give you an approval on a pre-authorization and then deny the claim, it is a lot easier to get that now paid because you have proof that they had given you a pre-approval. Um so, that can be helpful, but again, lot a lot longer of a process, and what are

we training the insurance company on? We're training them that we're playing this kind of game with them. And you could be tied to old lower fees and some of those pre-auths instead of using the insurance commissioner, uh taking back that power and getting paid on your current increased fees, hopefully. >> Yes. >> Um yes, to dive into using the insurance commissioner. Um so, we're saying that that first step, you you dot your i's, you cross your t's, you make sure you've done everything correctly and that

that service should be paid. Now, when you go to the insurance commissioner, you know you have a case and not just with that one retreat denial, you're going to send all of those denials over to the insurance commissioner. When we see these patterns that you're seeing, the insurance commissioner needs to see them as well and you have to point out and ask them to see the pattern with you of these constant denials. One office can do it alone if you have a lot of these patterns

that you're seeing. But, when it's just one office, the commissioner is wondering if this is a problem of the office, not a problem of the insurance company. So, to make sure that the other providers in your area are also having the same problem and also reporting it the same way, this allows the insurance commissioner to see that the pattern is on the side of the insurance company and not at fault of one office's billing practices. >> Mhm. Yeah, this is huge because um, you know, doctors

have they attend study clubs, they have friends, you know, they're probably very Well, dentists are very active in terms of networking. And mainly because they're required to take CE to renew their licenses when, you know, every 2 years or so or I don't can't remember how long licenses last these days, but uh but for that reason, you know, you you definitely want to collaborate with your other colleagues in the same communities, but uh Tasha is correct is you can advocate for yourself, but you just have

to have your your documentation all put together that's easy for the insurance commissioner to read. How long does it typically take, Tasha, like what The moment the insurance commissioner says, "Yeah, we'll take this case on. We'll take a look at it." How long does it typically take for them to do their review? >> Yeah, it depends on each state and within each state how burdened the insurance commissioner is. Um, in the beginning, I was really easy, within 2 weeks for me. Um, we were getting payments

at these claims that And at the beginning, I was just like every other office where I would take me a year to get payment and five appeals and 10 appeals. And so when I started using the commissioner, it took 2 weeks. I was blown away. And then I started doing that one appeal and commissioner. And it was so much faster than any other appeals method I've ever tried. Um it was so amazing. So now um because of my efforts of teaching offices >> [laughter] >> how

to use the insurance commissioner, they're really backed up. They're really behind. They're not staffed for what uh they weren't prepared for what I was bringing. >> [laughter] >> And um it can take a month. It can take a month to 2 months. Um but I am assured that they're going to get it resolved and that that payment is coming. I don't have to call on it every week. I don't have to fight and argue with anybody. I know that it's in good hands and I just

patiently wait. >> Yeah, that's that's good advice because here in Utah, you've done a great job at getting doctors to use the insurance commissioner. But all the other states that are out there, their insurance commissioners have plenty more plenty of time. We're We're the only state in the country that our insurance commissioner is as busy on dental-related issues compared to all other states including California, Texas, and New York who have much larger a larger presence of dentists, we're the busiest. So the goal is to sort

of uh use the insurance commissioner more effectively. So I highly recommend that if you're in this mix of dealing with constant denials, what I learned from Chessna is that once you sort of have these issues buttoned up with the insurance commissioner and you're repeatedly using the insurance commissioner to fight insurance for your practice, does that have an impact on a reduction of denials and a reduction of abuse from insurance carriers? And Chessna is nodding her head and saying, "Yes." Can you speak to that for a

second here? A sort of the uh uh uh a side benefit other than getting our claims paid, how does this help from a long-term abuse perspective, standard abuse perspective when we're dealing with insurance from a long-term perspective. >> Yeah. So, definitely it's going to be a reduction in denials. Um not even just for your office sometimes. I have seen where they have been if they're seeing this repeat offense that where it's a trend of these denials, they will actually run an investigation and go and tell

that insurance company to knock it off for their entire state. So, insurance commissioners per state, they only have rules for their state. They have the ability to tell that insurance provider that they cannot uh sell insurance plans in that state anymore. This would be detrimental to a company. They don't want this. Um so, they want to play ball. They have to play ball with the insurance commissioner or they're kicked out of the state. But well before that, um the insurance commissioner will just give them a

fine, tell them to clean up their act, and they can stay. So, again, when we are reporting something like a trend, not only is it less denials for your office, my number one role is get your office on their whistleblowing list. As long as you are notifying them and reporting them, they're going to back off of you because they can keep doing it to everybody else as long as they don't get told to stop. So, if you are the only office reporting, by all means keep

doing it and least they'll back off of you. Now, if you get your whole community involved, um they're going to see these trends and they're going to tell this insurance company that they have to stop automatically denying all retreats or they're going to be fined. That is not allowed for them to have an automatic flag for based on procedure. Um not based on what the office is submitting. And that's what it sounds exactly is happening with these retreats. Um it's flagged in their system. As soon

as they see it, it just gets pushed for a denial. If we can get an investigation run, the commissioner's office will find that flag and they will tell this company to remove it. So, again, you're not just benefiting yourself or the three offices that are involved in this, the entire state would benefit. >> That's awesome. It's a It's a consistent trend of messages that I hear around the country from doctors the practices and administrators that use your same approach. Is that long-term it does lessen the

abuse the the denials from insurance carriers and subsequently what that does for a practice is it reduces your overhead. It reduces the unnecessary payroll dollars that are spent on administration issue that you could easily resolve through the insurance commissioner and have a long-term fix, you know? So, Tessina, this is amazing. Um you know, I I want to share your contact information with our listeners so that if they have questions about this, I highly recommend retaining Tessina for uh anything as it pertains to coaching with insurance

denials, [music] you name it, right? Tessina is a pretty good expert there. What's the best email that that listeners can get a hold of you if they have questions about this? >> Yeah, it is tessinabarney@gmail.com. It's just t e s f i n a b a r n e y @gmail.com. I know that is Was that long? Is it long? >> That's good. I'll post that in the show notes and then and then Tessina's company's website is verusdental.com. That's v e r u s dental.com. And

we'll have that in the show notes for for listeners that are interested in anything that Tessina provides as a service. Uh Tessina, thank you for being with us today. This has been an amazing episode. Really appreciate it. >> [music] >> And to our listeners, we want to thank you for joining us today on another amazing episode. If you like this, share this with your team, [music] social media, other doctors that are out there. Give us Give us some love with some five-star reviews. That'll help other

doctors find our content. Don't forget to check check out our websites. We have two websites, saynotoppos.com. And then Sorry, not verusdental. It's insurancetangle.com. Uh that'll go over the quarterly webinars as well as all the other episodes that we published in the past. We thank you again for joining us today. Until we meet next time, we wish all of you the best of success. Take care, everyone. >> [music] [music]