Can HIPAA help me appeal a Dental Claim denial?

May 31, 2006 2:13 PM

What is the best approach for appealing a dental insurance claim that was denied for a pre-existing condition when I have had continuous coverage? Does HIPAA apply?

My employer changes Dental Insurance companies almost every year. When I was first hired 4 years ago, I had an extraction under a different insurance company. After 4 years of dental work, I finally got a bridge spanning the extraction.

My current insurance company denied the claim for the bridge because they were not my insurance company when the extraction took place. Can they do this if I have had continuous dental coverage?

I have no control over the "musical dental plans" game that my employer plays. Do I have any recourse? Do the recent HIPAA changes deal with this circumstance?

posted by eisbaer to health & fitness (6 answers total)

Hell, yes, appeal it. They just want to see if you'll take the bait and cough it for yourself; it's free money to them.
posted by SpecialK at 2:16 PM on May 31, 2006

Sounds like you certainly have grounds for appeal. As long as there is continuous coverage by a group plan. Your employer didn't convert your group plan to an individual, private account? HIPAA does not cover the move from group to private coverage.
posted by Thorzdad at 2:22 PM on May 31, 2006

for a living I am a dental practice administrator, and this sounds insurance scheme is common. It's called a missing tooth clause, and it happens all the time. They probably won't pay.
posted by bilabial at 2:25 PM on May 31, 2006

bilabial,
How do they skirt the HIPAA requirement for continuous coverage? What's the (apparent?) loophole they are exercising?
AFAIK, if you were covered for a procedure or condition under plan-A, HIPAA requires plan-B to cover it too.
posted by Thorzdad at 4:58 AM on June 1, 2006

Not enough information. Either: (1) one or more of the dental plans you have had is not creditable; (2) your current insurer thinks one or more of the dental plans you have had is not creditable, but is wrong; (3) all bridge work is not covered under the new plan and they have a weird way of saying it; (4) the new plan thinks the bridge was not necessary and they have a weird way of saying it.

Obviously, you are rooting for (2), which is easily correctable. Number (4) is arguable.

It would be a really good idea to talk to your HR representative. They should be a liaison between you and the insurer. They pay the insurer for a service, and it's in their best interest to make sure that service is provided correctly. The HR rep and the insurer can talk in Insurance-Speak, which the HR rep should be able to translate into something you can understand.

If for some reason your HR rep is unwilling to help (it happens), then call the customer service number on your ID card. Talk to someone. If you don't understand, tell them so and ask to speak to someone else. Be nice. Insurance company employees often don't realize they are speaking completely unintelligible gobbledegook.
posted by deadfather at 6:20 AM on June 1, 2006

There could be all sorts of ways to "skirt" continuous coverage. The one I am most familiar with, again, is the "missing tooth clause."

There may also be a three year waiting period for any crown and bridge work.

Dental insurance isn't really insurance, in the sense that there is a very tight maximum on your benefits and they take little (if any) consideration of an individual patient's clinical needs. Patients with rampant periodontal infection being told that they "may not get dental cleanings more than twice per year" or "more than once in a 6 month period" outrages me, because some of these phone agents aren't even telling patients they have the option of paying out of pocket for their care. They are more than happy to suggest to the patient, however, that a doctor's fees are too high and then provide a list of dentists contracted to the PPO whose fees are so low that quality of care may be compromised.

Anyway, yes they can do this. Next time you have to have an extraction, get the rest of the prescribed treatment immediately. If that is bridge, or implant or whatever, do it. There are dental payment plans that will make this possible if you are about to call the budget card. (CareCredit from GE and also one called Dental Fee Plan from Capital One.)

If you want to have more control over your dental benefits, select a plan yourself and pay it out of pocket and leave your employers choice out of the matter altogether. They play these yearly pricing games to be able to say they offer insurance. They do nothing to assure you any level of care.
End of rant.
posted by bilabial at 5:52 PM on June 10, 2006