аЯрЁБс>ўџ 79ўџџџ6џџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџџьЅС#` №Псbjbj\.\. .&>D>DсџџџџџџЄЄЄЄЄЄЄЄИм м м м № ИЖ        šœœœœœœ$бh9ŒРЄp   p p РЄЄ  еlllp Є Є šlp šllЄЄl  `!#B<9Ъм † "lšы0lХЈ ЎХlХЄz  ЎО |l: dž в   РРV   p p p p ИИИ$м ИИИм ИИИЄЄЄЄЄЄџџџџ Dear _____________, As you recall, last year you decided to proceed with treatment for periodontitis (gum disease). At that time, we provided you with several treatment options including long term maintenance, scaling and root planning, laser periodontal treatment, or referral to a periodontist (gum specialist). Based upon our discussion and your stated desire to avoid traditional scalpel and suture surgery as preformed by the periodontist, it was determined that laser periodontal surgery would be the best option. My front desk staff then sent in a pre-determination of benefits to Delta Dental of Michigan to see if any benefits would be payable for the procedure. Code 4260, according to Delta Dental’s own utilization guidelines, requires the determination to be based on the submission of Full Mouth Radiographs and Periodontal Charting only. There is no Delta Dental requirement of ‘by report’ for this code. Delta Dental replied with an estimate of what they would pay for the proper American Dental Association Procedure Code of 4260. The procedure was accomplished and submission for payment was made to Delta Dental in a timely manner. Delta Dental paid the claim as it fulfilled their stated requirements. Last week I received a certified letter from Delta Dental of Michigan. stating they would be auditing records for three of my patients to determine compliance with the DeltaPremier and Healthy Kids Dental/MI Child Participating agreement. We have sent the records registered mail. Based on reports from other Michigan dentists who have undergone this audit I should expect the following: To be asked to submit ‘by report’ details of how this procedure was preformed. (Remember, Delta Dental’s own guidelines don’t require this). Delta will reverse their decision to pay benefits under code 4260. Based on reports from other Michigan dentists who have undergone this audit you should expect the following: Denial of benefits paid, because Delta has determined in the summer of 2009 (approximately a year after your procedure) that they consider the use of a laser in this procedure ‘investigational’. When this determination officially is made, the benefits agreement /contract with Delta Dental of Michigan will transfer the responsibility for payment from Delta to the patient for this procedure. Delta will also start deducting money from future payments I receive (for other patients procedures) to recoup their money. This is blatantly unfair both to the patient and the dental practitioner. My recommendations for resolving this would involve the following; When you receive the letter of denial of benefits your first action should be to contact the head of Human Services for the employer who supplies the dental benefit. Explain to them the situation (or have them contact me) so they will realize they are paying a premium based on a certain level of coverage which is not being provided by Delta Dental. Quite often, just hearing from the employer H.R. person will cause the insurance company to re-evaluate the situation. Secondly, I have enclosed a copy of a complaint for which can be filed with the Office of Financial and Insurance Regulation of the State of Michigan. For our part we will also file a complaint with the same office. If there is no resolution at that level, the next step would involve the Attorney General of the State of Michigan and the Federal Trade Commission. You should also know that this is only a problem in Michigan for patients who have Delta Dental as their benefit administrator. No other insurance company in the country has denied these benefits. It is also interesting that no periodontist (gum specialist) in Michigan have been targeted for this review and none of their patients have been denied benefits from Delta Dental, even when they have been trained and licensed to perform the same procedure, using the same code. If you would like copies of the science that clearly show this laser assisted procedure is not ‘investigational’, I would happy to provide such. Needless to say, based on almost seven years experience, performing this FDA approved procedure (Laser Assisted New Attachment Procedure); I am still amazed at the outstanding results it provides and believe patients should not be denied its availability because of a dental benefits provider’s reversal of a previously approved procedure code. I appreciate your assistance in this fight. I appreciate the confidence you placed in me when you allowed me to provide treatment for your periodontal disease. Please know that we will continue to fight tirelessly to try and get this expected decision reversed. If you have any questions, or if we can be of any assistance to you with your interactions with Delta Dental, please feel free to contact me. 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