Patients with dental coverage usually believe that any necessary procedure will be covered. When a denial comes back on a medically necessary procedure under the missing tooth clause, they’re likely to be shocked.
A missing tooth clause is a provision in the contract with the insurance company that states if a tooth is lost before the contract begins, it will not be their responsibility to cover replacing the tooth (or teeth) with a crown, bridge, or implant. You can describe this to your patient as the preexisting condition of dentistry- as that’s a term they are likely very familiar with from medical insurance.
This affects many of your adult patients as 69% of adults 35 to 44 years old have at least one permanent tooth missing. Insurance companies will also claim this applies in cases of patients with a congenitally missing tooth.
This lack of coverage can significantly impede your patients’ access to necessary dental care. This article will discuss how you can best support your patient to ensure they get the necessary treatment in situations where a missing tooth clause may apply.
Patient Education Is The Best Prophylaxis
A significant part of the work you can do to avoid this issue is patient education. Approximately 90 percent of today’s dental plans have a missing tooth clause. You must advise your patients to read the fine print of their insurance plans. Your patients need to know this clause’s policies, terms, and conditions.
Patients need to understand the importance of having dental insurance before they need it. In some cases, the insurance policy will cover tooth replacement costs, but only after a waiting period is over. This will usually be anywhere from a couple of months to a year. It’s also helpful to know the few insurance companies that do not include this clause and share a list of names with your patients.
A Predetermination And Detailed Treatment Plan Are Helpful Allies
The possibility of a missing tooth clause-related denial is a major reason dental offices need to do predeterminations. This is an important point to emphasize with your billing department. It may seem like a claim will be cut and dry in the present moment, but it’s vital not to forget about the history of a particular tooth. Insurers may deny claims citing a missing tooth clause when you and the patient are not expecting it. A predetermination will ensure your patient has the necessary information to make a financially informed decision on their treatment.
The second thing your billing department can do is provide the patient with a treatment plan after the diagnostic appointment. This will both help your patient be informed about their course of treatment and support them in being able to advocate for themselves with their insurance company.
Be Prepared To Send An Appeal And Have Appropriate Documentation Ready
If the appeal and appropriate documentation steps have been followed and you still get a no-pay, the documentation you have created will still ensure you and your patient have the information to support your appeal. Sometimes, the first appeal will overturn the original decision, and benefits will be paid out. At other times, a second appeal will be needed or a peer review will be requested.
It’s wise to have a missing tooth clause appeal template. This will help you save time and be efficient since most of the appeal will be the same for every patient. This appeal will explain to your insurance company that your patient would not have agreed to the service if payment was not going to be provided. Your documentation will provide proof that you and your patient did the necessary research on compensation for the procedure.
The insurance company will sometimes waive this clause if you can prove upon appeal that the patient had switched insurance companies but had no lapse in coverage. That means your patient was never without dental coverage. You can get a certificate of prior coverage from the former insurance company to demonstrate this. In order for this to work though, the former plan will likely need to have had similar benefits.
Prepare And Educate To Ensure The Best Outcome For Your Patient
Missing tooth clauses can pose a financial challenge to your patient’s treatment plan so it’s important to know how to work with these effectively.
Key points are to educate your patient on missing tooth clauses before they choose an insurance plan, to ensure you have done a pretreatment estimate, and to have the relevant documentation on the payers’ policy should you need to file for an appeal. Also, when possible, provide evidence of your patient’s previous insurance company to show there was no lapse in coverage.
These steps will allow you to advocate for your patient or at the very least prevent them from being surprised by a significant out-of-pocket expense. This is key to having patients that trust in you and your team and to building a financially sustainable healthcare plan for your patient’s dental care.
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