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John LeitnerSpectatorStrange – I haven’t heard anything from Delta yet either. I did send in one of the three cases they asked for with one year post-op probings (I know, they didn’t ask for that!). Maybe they saw the numbers and it made them think — NAHHH! The patient and I were quite happy with them, maybe Delta wasn’t. I could send them the other one year post-ops now, but I won’t stir it up again. Waiting….
John LeitnerSpectatorLet’s see now – mid May and still waiting – – -. John
wagoodellSpectatorSam heard from Steve Knowlton in St. Clair Shores. He also was put on notice that he is on Focused Review for “all gingival flap and osseous procedures starting October 1st.”
John LeitnerSpectatorYep – me too Brutus!!
Michael AielloSpectatorDuring my battles with Delta, Tom McClellan informed me as I stated previously. Delta will allow you to bill for alternative benefits. In the case of denied D4250 (LANAP) I have billed for SRP and occlusal adjustment. These have been paid. As long as the patient is eligible for these these services they should be covered.
As for LANAP I was told I could bill the patient since coverage was denied. On some of the submissions Delta had changed its status to “disallow.” Disallow means you can not bill the patient. In these referenced submissions, Delta did back down on its disallow position and reverted back to denied .
Michael AielloSpectatorRon,
I received denials upfront. In my situation Delta decided that they would assume all osseous was using the laser, therefore it didn’t qualify for coverage.
The disallow situations came about right after I sent a formal complaint to the OFIR (Ins Commiss). Seemed like they were playing hardball.
Its a waste of time to Pre-D surgery since Delta will deny the claim once they review your charting after the fact. During focused review you have to send a copy of the charting including treatment notes. If Delta treats you the same as I, it will go as follows. If you don’t list what you used and how, Delta will deny the claim and then tell you they assumed you used the laser.
If you did “traditional” osseous without laser, sutures used, etc.. then you have to prove it. Delta told me that they would consider contacting patients directly to verify. ( Check to see if I was lying and committing fraud)
Michael AielloSpectatorYes. Delta doesn’t recognize use of the PerioLase during D4240, so its treated the same as D4250.
Either way you have to prove to them what technique and devices were used. For coverage it has to be traditional scalpel and flap + sutures. Otherwise you should be able to get alternative benefits such as SRP and occlusal adjust.
Michael AielloSpectatorRon,
For Delta patients I try to keep it simple. They are told that their insurance covers a portion of what we do during LANAP. We estimate what full mouth SRP coverage is and tell the patients that this dollar amount is what we estimate the insurance will cover.
Internally we take our LANAP Fee and subtract the SRP benefit. E.g. LANAP $4,000 – 4 Quads SRP $1,000 = $3,000 Pt portion
We don’t bother with guessing if splinting, occlusal adjustment, or other billable treatments would be covered. After LANAP we will bill Delta for these “alternative benefits” to help the patient out. This way the patient is grateful if they get additional money back.
If you are allowed, it is easier to bill directly to regular Delta (vs. Focused Review) for these covered benefits without bothering to submit for payment of D4260/D4240 through focused review.
For rejected LANAP we used to bill Delta for SRP, occlusal adjustment, or any other legitimate procedure performed without going through the focused review address. Then Delta changed its policy and flagged the billings that were denied D4240/D4260 and sent these claims to focused review.
In my situation Delta wanted us to send in LANAP by using code D4260/D4240 with our charged fee and include D4999 with LANAP fee less SRP fee. To me, this gets confusing. That’s why, if you are allowed, skip focused review since LANAP won’t be paid for anyway and bill regular Delta for those procedures that may be covered.
We don’t hide the fact that insurance coverage may be higher for scalpel osseous surgery but we also stress it is up to the patient to weigh the pros and cons of each treatment. For patients with low insurance maximums it is not as punitive as those with higher.
The bottom line is that Delta will pay for SRP and typically occlusal adjustment. The rest is out of pocket.
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