Coding case study: Midyear changes can impact your reimbursement

2016 08 12 15 05 28 688 Doctor Form 400

If your practice accepts insurance, you've probably been faced with a situation in which the provider implements contractual changes. And sometimes, despite everyone's best efforts, you find yourself unprepared for the effect of this change to your reimbursement projections. is pleased to be able to bring you this coding case study originally published by the California Dental Association (CDA). Whether you practice in California or not, the suggested ideas to address the potential impact on your practice's revenue may be instructive.

The scenario

In a letter mailed to participating providers in January 2018, Delta Dental of California shared revisions to its provider participation documents. Appendix A -- California Participating Dentist Rule 2 -- was revised to the following wording:

Basis of Fees. A participating dentist will accept the lesser of his/her "Contracted Fees" with Delta Dental, or the fee submitted on his/her Attending Dentist's Statement, as full payment for services provided to any eligible patient. If the participating dentist does not have a Contracted Fee for a Premier program ("Premier Contracted Fee") with Delta Dental for a particular procedure submitted on an Attending Dentist's Statement, payment will be based on the applicable Delta Dental PPO (preferred provider organization) fee schedule(s).

The communication stated that the change would be in effect no sooner than August 1, 2018. However, CDA Practice Support recently confirmed that Delta Dental's implementation of this rule actually commenced on September 15, 2018.

The result of this revision is that dentists who do not have a Premier Contracted Fee on file for a specific procedure they provide will now be paid at the applicable Delta Dental preferred provider organization (PPO) fee.

Despite the advance notification, some dentists have now found themselves unprepared for the rule change and are experiencing a negative impact on their reimbursement levels on specific procedures.

The following case study is meant to help ensure dental practices are aware of the potential impact on their practices.

Case study

The following case study includes consideration of this rule revision when evaluating filing fee updates.

Dr. Smith's dental office has diligently updated its annual fee proposal with Delta Dental on June 1 of each year. The office manager received and carefully read the communication sent by Delta Dental noting revisions to their participation documents earlier in the year. The office manager was not concerned with the previously mentioned rule change as the office did not have any missing fee proposals on its schedule for services Dr. Smith performed with regularity.

On October 1, Dr. Smith performed a surgical sialolithotomy, listed as code D7980, and the office filed for reimbursement as usual.

The office manager then received an Explanation of Benefits from Delta Dental after the service was processed; the reimbursement was lower than anticipated.

On October 12, the office manager contacted Delta Dental requesting clarification on the reduced fee, and the representative explained that Delta Dental implemented the previously mentioned rule change on September 15. The representative explained to the office manager that Dr. Smith had not proposed a fee for the D7980 during his last fee revision, so when Delta Dental implemented the new rule, the fee for the D7980 was paid at the PPO rate.

The office manager was told that nothing could be done to have the claim recalculated because the rule change had been communicated to the dentist well before the required advance notification time frame.

The Delta Dental representative informed the office manager that the dentist could log in to his account in the Delta Dental Provider Tool and add a fee for the D7980, but it would reset their fee revision anniversary date, and Delta Dental would not make any considerations or revisions to codes that already had a fee on file.

The representative said Dr. Smith would be allowed to add a fee proposal for any code without a previously proposed fee to his schedule. The representative then explained that should Dr. Smith opt to add a fee amount for the D7980, his fee filing anniversary date would change from June 1 to October 12.

Dr. Smith's office manager then contacted CDA Practice Support for assistance with this issue, explaining how infrequently Dr. Smith billed for this code. Based on the information gathered, the analyst advised the office manager to consult with Dr. Smith and review the ADA CDT 2019 codebook. The analyst advised that the office evaluate the code changes and the potential impact of being paid at the PPO fees for those procedures that Dr. Smith regularly provides.

Given this information, Dr. Smith decided that since he rarely performs the D7980, he would not submit this fee proposal to Delta Dental until it adds the 2019 CDT codes to its fee revision template on January 1, 2019.

Had Dr. Smith added a proposed fee for the D7980 on October 12 and had he not carefully thought through his fee proposal to Delta Dental by including the CDT 2019 code changes, he may not have been allowed by Delta Dental to propose fees for the newly added codes for 2019 until October. 12, 2019, potentially causing a negative financial impact on his practice.

3 considerations

1. Time your fee updates strategically

“Replacing one missing fee to avoid the PPO reimbursement level may reset a dentist's fee filing anniversary date.”

Under Delta Dental's current compensation policy, contracted providers submit separate Delta Dental Premier fee update requests for each practice location, specialty, and Taxpayer Identification Number every 12 months from the last submission.

In light of the recent rule change, Delta Dental has been allowing dentists to submit a fee proposal for the missing code(s) on the dentist "Premier Contracted Fee Schedule." However, dentists are advised to evaluate the importance of adding any missing fees for 2018, while also taking into consideration upcoming CDT code changes effective January 2019.

Additionally, replacing one missing fee to avoid the PPO reimbursement level may reset a dentist's fee filing anniversary date.

2. Monitor CDT code updates carefully

The ADA's Code Maintenance Committee updates the CDT codes annually. Updated CDT codes are released in early fall for the following year. Additionally, dental teams are encouraged to update the CDT codes in their practice management software and review code changes prior to submitting fee revisions to Delta Dental or other dental plans.

3. Implement a dental plan document review process

Establish a system in the practice for reviewing dental plan correspondence to evaluate potential effects to payment and processing policies, recredentialing, and more.

Cindy Hartwell is a dental benefits analyst with CDA Practice Support, which is a CDA member benefit.

Disclaimer: This column is a case study of one practice's interaction with one insurer in California. It is intended to illustrate a common issue, and there may be variations among states and insurers. recommends you check with the ADA or your local or state dental association.

The comments and observations expressed herein do not necessarily reflect the opinions of, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.

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