b'FOR YOUR PRACTICEAsk the Coding CoachHave any of the following scenarios happened in your office?A claim was submitted and further documentation was requested multiple times. The requested attachments were sent multiple times without any resolution.A pre-treatment estimate allowed benefits for two implants to be used as abutments for a fixed bridge. When the claim was submitted for payment, reimbursement of the implants was denied.A new associate started in your office but there has been no response in over 90 days since you applied for credentialling. A claim was denied for connective tissue grafts performed onIn most clinical cases, after contacting the carrier, they will let Dr. teeth #24-25 due to lack of recession.Schweinebraten know if and how the problem can be resolved. With administrative issues, it is normal for the carrier to contact the office Issues such as these cause frustration for the periodontist and thedirectly. staff, as well as the patient. The AAP has a service for membersThe AAPs track record is good, with the majority of clinical claims that is unique to our specialty: the Complaint Resolution process,being addressed satisfactorily. However, there are cases where the which was established to address periodontists problems withdecision cannot be reversed because of plan limitations or policies. third party payers. The examples mentioned above are actualAdministrative complaints are more varied and more complicated. cases that have been resolved for offices.Some can be resolved quickly, while others take time to review policies The AAP receives over 1,000 calls and emails annually fromthat are in place. There are even instances where a carrier is unaware members who have problems or questions about reimbursementa problem exists, such as wording on an EOB, for example. and coding. In most cases, the AAPs Third-Party Specialist canIn addition to this important part of the AAPs third-party services, help the office resolve their issues. Other times, however, thethe AAP also works behind the scenes for members. Annually, AAP carriers must be contacted. If a claim was denied after a writtenstaff, the Insurance Consultant, and the Chair of the Patient Benefits appeal, such as in the examples above, the AAPs Insuranceand Advocacy Committee meet one-on-one with dental directors of Consultant, Dr. Marie Schweinebraten, can contact the carrier oncarriers at the American Association of Dental Consultants meeting. the offices behalf.This gives the AAP a chance to express concerns we have seen over Some cases are claims based and thus, clinical in nature, suchthe past year, as well as answer their questions about current trends as denying soft tissue grafts due to lack of recession. If this is thein periodontics. case, then a complaint resolution form must be filled out, whichThe AAP also participates in national insurance related committees can be found on perio.org. It includes basic information such asand workgroups such as the Code Maintenance Committee, the insurance group number and patient ID. The form also must beDental Quality Alliance, and the Standards Committee on Dental signed by the patient for HIPAA compliance. The original claim,Informatics, including SNODENT. any attachments that were submitted, any communication with the carrier, all EOBs received by the office, and the written appealKnow that the AAP is working for its members in many ways to will need to be forwarded to the AAP. Once this documentation isreinforce patient advocacy and ensure that periodontics has a voice in received by the AAP, Dr. Schweinebraten can then move forwarddecisions and policies related to reimbursement and benefits. with the carrier to resolve the problem. If the issue is administrative, such as credentialling, EOB language, or even questions regarding fee schedules, then a complaintSubmit your third-party questions to insurance@resolution form and the patients permission is not necessary.perio.org. Members with coding questions or However, all pertinent information should be sent to the AAP. Thisdifficulties with insurance claims can also contact includes names, office addresses, and any communication withthe AAPs Third-Party Specialist at 312-573-3241 the carrier.or michellef@perio.orgAAP Periospectives| 33'