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onlay claims. Therefore, if you get a fast
denial, chances are it was never even seen
by a person. The challenge is to get away
from auto-adjudication, if possible.
One of most effective methods of getting
appropriate reimbursement is to docu-
ment.We are all aware of how some proce-
dures require radiographs, but how effec-
tive is this intellingthewholestory? It’s like
asking if the CEREC 2 is as good as what
we have today. One of my protocols is to
take a pre-operative intraoral image of the
tooth I am treating. Aside from providing
excellent medical-legal documentation, it
also provides much of the story of why you
chose the restoration you did. Treatment
images demonstrating internal fracture
or thin walls are also very telling. Finally,
screenshots of your final proposal of your
restoration can show, without question,
what restoration was placed.
Will you need to provide this level
of detail in every claim? Certainly not;
however, your business office can let you
know which benefit companies are more
problematic. The bottom line is, have the
information should you need it. Gathering
the documentation is extremely easy and
typically can be delegated. It’s the spare
tire theory: when you have a good spare,
you rarely need it.
Two other things can help change the
culture regarding reimbursements. One is
getting the patient involved, more impor-
tantly their HR department. Second is to let
the American Dental Association know of
what challenges there are andwithwhom.
It is important to note that any commu-
nication we will have with a benefit
company usually costs them money.
And, since we are not providing revenue
for them, we therefore can and should
certainly enlist the help of those that do
provide the revenue. With the Affordable
Care Act set to take the next large step
in 2014, we have the potential to see an
increase in individually purchased plans.
By starting today and giving the patient
a better understanding of their benefit
packages, they will see that the lack of
benefit comes from their plan, not your
office. This will put your office in a better
position come 2014. Yes, this takes time,
but if you are doing a significant number
of CEREC restorations, chances are you
are already spending the time needed
to enlist your patient’s help. If patients
understand a plan is not providing value,
the plan could be forced to change to
adapt to these patients’ desires and wants.
The American Dental Association main-
tains a regular dialogue with dental benefit
companies through the Council on Dental
Benefit Programs. While the staff is always
available by phone or e-mail to answer
member questions, a very efficient and
effective method to communicate these
issues is to utilize the online complaint
form (
www.ada.org/ada/dentprac/default
.
aspx). This form allows not only a quick
way to report issues but also provides the
ADA metrics that can be used to address
these issues in aggregate. The url is: www.
ada.org/ada/dentprac/default.aspx.
Your mantra should be “code and bill for
what you do.” Trying to produce a benefit
where there is none threatens your license
and creates a disservice to other dentists
and their patients. As CEREC continues to
grow (especiallywithOmnicam), ceramics
will continue to be a bigger and bigger
portion of treatment performed. If we
dismiss the bad information many of us
have heard on the lecture circuit that an
onlay is when you go up a portion of a cusp
or a surface as you encroach the surface,
we will all be much better for it.
We are providing our patients a great
service with CEREC restorations. Let us
continue that great service into theprofes-
sion by being transparent in reporting our
treatment codes.
Stephen C. Ura, D.D.S., M.A.G.D., is a
private practitioner in Nashua, N.H.
He is the immediate past vice-chair of the
American Dental Association Council on
Dental Benefit Programs and the immediate
past chair of Subcommittee of the Code. He
has actively participated for the past four
years in the code revision process both on
the Code Revision Committee and Code
Advisory Committee. He may be reached at
scuradds@mindspring.com
References
1
American College of Prosthodontics;
The Glossary
of Prosthetic Terms.
The American Dental Association's third-
party payer complaint form is available at
www.ada.org/ada/dentprac/default.aspx
.