How to Approach an SRP Claim Review with an Insurance Dentist Reviewer

Many of us end up dealing with SRP claims denials at some point. In a recent case I had to talk to a dentist reviewer. This conversation came after an SRP claim was denied for the second time. We’ve submitted over 300 cases of SRP each year, and this is the second perio case that went past submission #2. The reviewer was very pleasant, but it was obvious that he was well trained on how to dispute every possible come back; but he chose the wrong person to disagree with. We got the claim paid when they had already denied it twice.

Here is a basic outline of how to fight denials on the phone:

1.) Don’t let the reviewer focus on X-rays: In many periodontal cases there is minimal bone loss, but obvious vertical attachment loss. Focus on getting the reviewer to agree to seeing those sites. Then, if they want to continue to fight this, fall back on the true definition of periodontal disease, which is from your CAL (not x-rays).

2.) Don’t let them minimize the problem: For example, "Only 4mm pockets" on the top....and ‘only’ a couple of 5-6mm pockets on the lower...” Periodontal disease is a problem that needs treatment no matter how early or late stage it is. Focus on the clinical attachment loss shown. Make sure to always have good measurements of gingival margins so you can get a true CAL measurement. Get the reviewer to agree to how the AAP and periodontists define periodontal disease by CAL, not pockets or x-rays. Every quad when counting CAL has multiple teeth with problems that justify SRP.

3.) Submit Clear Photos: In this case, we did not talk about this since I had clear photos, but it always helps to have pictures of the perio probe in place showing not only the depth, but also the blood. Photos are worth more than almost anything else you can send (other than the perio chart).

4.) Pseudo Pocketing: The one mistake I made was not marking GMs on every tooth. He brought up swelling in tissues and possible pseudo-pockets. We had enough measurements of GMs to get undebatable CAL, which closed the case and had him agreeing to approve treatment. The lesson learned here it to mark literally everything, including zeros, and you will remove the ability for them to argue pseudo-pocketing.

Moral of the Story: your perio chart is everything. Fail to get every point, especially bleeding and gingival margins to have accurate CAL and you will deal with denials. Present a FULL perio chart and there is not much to debate. 

When talking to reviewers, remember they are dentists. You can have whatever opinion you want, but being professional will get you further than being rude. The entire conversation with this reviewer was pleasant; and in the end, he kindly agreed to approve the case. These dentists potentially can help you, making them mad is not the way to go.

Remember insurance companies are after the low hanging fruit, i.e., offices that are easy to deny due to missing information or lack of pushing back. Push back and they will go after another piece of lower hanging fruit.  

If you would like more detailed information on how to get 99% approval on SRP claims, please check out this online CE course: Achieving Reimbursement for Periodontal Treatment