Kinzie Hess Broxon answers viewer questions about PPO insurance and how to approve your claims and lessen appeals.
Kinzie Hess Broxson of PK Performance Solutions
She was initially from the banking industry and found herself in a multispecialty practice learning from someone with expansive experience in insurance.
What is the biggest reason for denial? Before the submission, make sure that your narrative, Xrays, and codes are correct.
Play the game, know what you’re looking at and that it’s listed with the correct tooth and code.
What about perio? How can we get our SRPs approved? Have perio charting show CAL, need pocket depth, gingival margins, FMX for the quadrants for the requested areas. A narrative needs to discuss heavy bleeding, vertical and horizontal bone loss, moderate sub super calc. You can’t get by with bitewings along, and FMX is needed to show history.
What about downgrades on crowns? Photos are helpful to send it on the initial claim to prevent appeals. Buildups should have a before, during, and after photo to include
Can you get diagnostics from a new patient if the previously went somewhere else? Some plans will allow for an additional exam as part of history, but your initial BoB needs to ask about the specific codes.
The most rejected claims come from United Concordia and Delta, and United is notorious for denying buildups.
To get buildups, show specific narratives to each patient. Do not use a form set for submission because they will deny it.
What are some common denials? Implant and bridge issues can sometimes be rejected or downgraded. Read into the patient’s medical history for specific causes for the decision you made.
Is a pre-D required? Doing an efficient breakdown and remembering that a pre-D still does not guarantee approval.
What do we say to patients to keep them satisfied with the process of what can be covered? Things that are typically not covered, leave the full fees and explain that they typically don’t cover it, but try to submit afterward with a good narrative. Your patients will be very happy to get a credit if it comes through.
Do repair codes ever get approved? Not for sealants and typically not for crowns. Denture and bridge repairs are more likely to be covered with a good narrative.
Has there ever been a time when FMD and comp exam on the same day? No, it goes by the ADA standard. Pairing it with other treatment makes it feel more productive to the patient.
Localized delivery of antibiotic, why do they only cover one tooth? It is typically not covered and she charges the patient for it.
As an OON practice, what percentage should we estimate as partial payment? Typically drop whatever the suggested coverage about would be by 20% for a better estimate.
Doing sufficient questioning and health history gives a better understanding of what will be covered on items like bridges so that you know how a missing tooth clause will apply or downgrades will be done.
If insurance won’t pay the claim and we know, just skip it. The exception is if your state law requires it. Also, check if there are required forms the patient would need to complete. Not submitting may help the patient through frequency issues.
What is the best way to get the new gingivitis code approved? Similar to perio submission, use photos, Xrays, and sufficient narratives.
Can we get inlays and onlays as well? The narrative should say what is going on with the surfaces and why the procedure was selected. Make sure to ask in insurance processing about any downgrades.
The patient gets a crown, then later needs an RCT and opts for extraction. Do we need to reimburse and notify the insurance company? No treatment changes are okay, but be aware of potentially going over on benefits for the extraction.
Which insurance covers a CT scan? Typically the medical portion would not cover, and at the least, the patient out of pocket on medical is much greater.
Do you recommend filing for a transitional denture for overdentures or having the patient pay for it? They will max out from all of the procedure. Look at timing to stretch the treatment over two calendar years for maximum reimbursement.
Do they ever cover oral or dietary education? No, it’s more to match their notes.
If someone gets laid off or quits in the interim before final seating, insurance will not pay, period.
PK Performance focuses on training your team on the clinical aspects and how to document properly.
Is an interim partial the same as a 1-tooth flipper? Yes
To get approved for connective tissue grafts, make sure to use good narrative details and labeled photos and x-rays if possible.
PK performance is online learning that engages the student in learning the material. Knowledge checks check for understanding and retention.
The learning is based on units that have 6 units, so they won’t have to go back to step one and can customize a plan or start the student from the very beginning for a new hire. You can customize it to your needs.
How do you pay staff for the training? If you are paying them to do it after hours, check the log to clock their hours and pay accordingly.