Ron,

I don’t know if Delta will request money back. When I was put on focused review they said they found some cases that they paid that “in retrospect” they would not pay going forward.

For me, Delta did not demand any money back, they just refused to pay for 4260 going forward. It may interesting to see what they do now. If they allow you and others to keep the payments from claims prior to focused review this may raise more questions. It would be another possible example of selective enforcement since they haven’t paid us over the last year and a half (while on focused review) during the same time span.

Obvoiusly this isn’t a question I would raise to them being that it may put others at risk. On the other hand it is good to know for building our case. After all Delta had other means to notify dentists of their LANAP position rather than after the fact focused review.

Ron,

I would hold off on your letter until you know if Delta will try to recoup the payments. My guess is they won’t, since this will keep the patients from filing insurance complaints.

You may want to rework your letter or use my version of it when you run into any payment denials.

In my case Delta did not request money back, but they did refuse to pay on cases submitted after the effective date of focused review. They use date of receiving claims, not date of treatment.

For my Delta patients now, I’m telling them that SRP portion will be covered. You can submit this bypassing Focused Review. They are informed of the exclusive fight with Delta. The choice is accept lower coverage with SRP or submit 4260 to Focused Review with the hope that we get a favorable decision prior to Ins time limitations expiring. Otherwise we treat it like no insurance.

Unfortunately, I heard some dentists are not doing LANAP on their Delta patients.

A bigger problem is one case I have with dual insurance where Delta is the primary. I can’t figure out how to get the secondary to pay without involving Delta claim denials. In the back of my mind I am thinking Delta would like another carrier to see their rejection to raise red flags and have the secondary company look into joining their position.

For the above case mentioned, I’m awaiting the Ins Commission response prior to further action. As soon as I get the response to my complaints I’ll contact Bob and post.

Bob,

I should have been clearer. The situation of dual coverage mentioned in my post has been submitted and is being fought with Delta. My problem on this one a bit more complex. Since I’m fighting the denial with Delta they won’t send me a rejection on their claim form. Without the rejection, I don’t have anything to send to the secondary to allow the secondary claim to be processed. If the State Ins Commission rules in our favor then its all a non-issue.

My complaint to the Ins Commission goes beyond LANAP. It also has to do with Delta “judging” techniques and methods. Delta has clearly implied to me in writing that they won’t pay for 4260/4240 unless all the steps of traditional surgery are performed and anything else is “investigational.” To me this is a case of Delta redefining the code (among other things). I’m holding off responding to Delta’s request for “more descriptive information on my techniques and methods” until I hear from the Insurance Commission.

Since I won’t give Delta more information, they won’t send an official claim denial. What I do have is Delta’s 3 page letter telling me I did not provide enough information and that LANAP or laser based surgery is not covered. This letter implies LANAP is no better than SRP, is investigational, etc… It is not something I would send to another insurance company.

I feel Delta has enough information. The chart copy they have lists the procedures that I did via the current MDT charting template. Delta also has a letter from me stating I did modify the bone to a more physiological form. What they want is me to clearly state what devices I used and how they were used.

They have gone as far as asking me to tell them how much bone was removed.

Does anyone recently put on Focused Review have any news to report? I’m especially curious to find how Delta handles the payment issues from the past LANAP cases that they review.

In my case, Delta did not ask for money back for cases prior to Focused Review. They did refuse to pay for future LANAP or anything that was not strictly “traditional” or “non-laser” surgery.

I have not heard anything new from the Insurance Commission regarding my official complaint. It is now four weeks since they sent me a letter telling me I would get a response (within four weeks).

Delta has taken a more aggressive stance within the last two weeks. I don’t know if there is any relationship with the Insurance Complaint. Previously they denied coverage for LANAP/Laser Surgery, but allowed me to bill the patients. Now Delta has sent new EOB’s that state I can’t bill these very same patients.

Delta’s reason: AP1490 Focused Review has disallowed this procedure because the required information was not received. Fee may not be charged to the patient if the dentist participates with Delta. The information Delta has meets their criteria for surgery. It includes the MDT bootcamp template and does not specify technique, use of laser vs scalpel, or methods used to modify bone.

Well, you could say I’m moseying along here on this one. We took off for the ADA meeting and gee – didn’t get to it right away. Now I got a note today saying I have 5 days or they will cut into future fees from my office. Interesting, what and were and how much will they take? Guess I’ll do it tomorrow, but I’ll write a nice note tonight first. John

The Delta letter was from Andrea Ruehle – provider auditor. uniform requiremtnt B-6 was the basis for the threat – we sent it today. John