Quality treatment and care bring patients to a dental practice. But to be sustainable, a practice needs to ensure that cash flow is not hampered by claim denials due to filing errors. There are multiple reasons why a claim can get rejected. From spelling errors to missing a few details, the reasons can vary. Some clauses are tricky when filing a claim. One such example is the “missing tooth clause”.
This clause is prevalent in multiple insurance plans. The dental team must be careful about such a clause, as treatments for cases like bridges, implants, or dentures might not get covered by the plan.
The implication for a dental practice could be unpleasant conversations with patients and alternative treatment recommendations. It could even lead to a loss in revenue. The team needs to understand how MTC works and can be applied when recommending the optimal solution to a patient. This can help in setting expectations with the patient and making sure that submitted claims are not rejected.
Many dental insurance plans incorporate a rule for a missing tooth. This means that the dental plan can limit the coverage for the replacement of teeth that were already missing before the commencement of the insurance policy. If a patient has lost a tooth before the dental plan became active, then the insurance firm might not reimburse the practice for replacing it with a denture, bridge, or implant. The insurance company safeguards itself from paying the practice for any pre-existing conditions. It would not want to cover treatment for issues or a problem faced by a patient before the patient was insured.
The dental team needs to understand that even if a procedure is covered by the insurance policy, the insurance company can deny reimbursement if a tooth was missing before the policy became active. Hence, a thorough grasp of the clause will prevent unwanted surprises for the practice or the patient before commencement of treatment and claim submission. Some reasons why the practice must have a firm understanding of the implications of MTC are as follows:
When the dental team submits a claim for tooth replacement, the insurance firm will always check when the tooth was lost. The insurance company will confirm if the tooth was lost before the patient’s policy came into force.
In the probability of the tooth already missing before commencement of the policy, and if the policy has an MTC, then the claim will be rejected. This clause is valid even if the policy covers the treatment itself, such as an implant or a bridge. Thus, the dental team must verify all details and take into account this clause before suggesting a treatment or making a submission.
Most patients build a relationship and trust with the practice. If a procedure conducted for a patient is rejected by the insurance company, the patient will usually pin the blame on the dental practice and not the insurance company. For any patient, frustration and disappointment are obvious when told that the insurance company would cover only a part of the bill.
The practice can lose out on a repeat visit and negative word of mouth. Besides losing out on the trust and confidence of the patient, a poor online review affects the practice, too. The ideal way ahead is to analyse the plan thoroughly, send a preauthorization request to the insurance company, and capture notes of conversations for possible queries at a later date.
There are cases in which a tooth can be congenitally missing in a patient. The clause still remains applicable as an insurance firm considers any tooth not present or missing in the same way. This means if a policy has a missing tooth clause, the claim will get rejected, irrespective of whether the tooth was never developed or lost at a later date.
The clause primarily applies to cases involved in the replacement of a tooth. This comprises bridges, dental implants, full dentures, and even removable partial dentures. This means that the clause can override coverage of all these treatments if the patient had a missing tooth before the policy came into force. It is important for a dental team to examine the dental history of a patient before any prosthetic treatment is recommended.
The best way to confirm if a patient’s insurance plan has a missing tooth clause is by verifying it with the insurance company. While analysing the plan details, the dental team needs to consider not only the general coverage. The team must give a complete nod of approval, whether or not the plan includes a missing tooth clause. For any prosthetic replacement suggested to a patient, the dental team needs to check the precise start date of the policy and confirm if the tooth was lost before that.
MTC is usually applicable only for a prosthesis that needs to be done for the first time for a tooth that is missing before commencement of the policy. If the dental team needs to replace an existing older prosthesis, MTC will not apply.
The dental team needs to be aware of any limitations that the patient’s policy might have. Some insurance firms might impose a time limit on how often a replacement can be done.
So, while MTC might apply, the plan’s timeline will determine the frequency of change in a prosthesis.
A few simple steps can ensure that the dental team handles MTC by safeguarding the interests of the patient and the practice.
An insurance firm can deny a claim based on the missing tooth clause without the dental team anticipating it. To avoid such situations, the dental team can request prior authorisation. This acts as a guarantee that enables the patient to make an informed choice whether to make a particular decision or not.
This helps the practice to get consent from the patient for the recommended plan. It will also offer a patient a clearer understanding of coverage and other out-of-pocket expenses. A dental team needs to send requests for preauthorization for multiple treatment recommendations, and MTC could be one of them.
The dental team can provide a recommended treatment plan to a patient after a diagnostic appointment. This can push a patient to connect with their insurance company. They can then understand the intricacies of their plan better, along with exceptions, maximums, deductibles, etc.
When a claim is rejected, an appeal is a must. This helps the practice to get reimbursed and makes the patient happy with the practice. When a claim has been rejected for an MTC case, the dental team must file an appeal and attach all relevant and supporting documents as proof.
It is possible that a decision can be reversed with a first or second appeal. The dental team can also maintain an appeal template for cases involving a missing tooth clause. An appeal with all documentation attached also acts as proof that the team had done due diligence before going ahead with the procedure.
It is vital for a practice to keep patients informed and aware of conditions and constraints regarding a missing tooth clause. This helps to keep patients from being presented with an unwanted shock of a massive out-of-pocket expense. It also helps to earn the trust of a patient who depends on the dental team to maximise the benefits of an insurance plan.
The dental regulatory landscape is complex. The guidelines or CDT codes continue to evolve. The dental team must ensure that it has a thorough understanding of limitations and clauses that can sometimes get skipped. The missing tooth clause is such an example. Capline Dental is a leading provider of end-to-end services to dental practices of all sizes in the USA and can be reached at info@caplinedentalservices.com
