How to Handle Dental Insurance Disputes

Dental insurance disputes are common in the United States. One of the reasons for this is that all insurance companies have different plans and reimbursement norms. There are two ways to address a dental insurance dispute. You can give in to your fate if your charges are termed UCR (Usual, Customary and Reasonable) and there is no chance of getting compensation. On the other hand, the matter may be worth pursuing if you can provide justification for your claims.

Difficulty: Moderately Easy

Instructions

1. Ensure that you involve all related parties. Talk at length with your insurance company and the dentist from whom you have received the treatment. Make efforts to resolve the issue without taking any legal action.

2. Send written communication if you do not want to talk personally to the dentist. The main purpose is to bring the issue to his or her notice.

3. Get ready to discuss key points when scheduling a telephone or personal meeting. Talk about the date of treatment, type of treatment, dollar value in the dispute, your dental plan, your side of the story and the final outcome. Dentists often have relationships with insurance companies and are anxious to solve major grievances.

4. Write to your insurance company and seek a solution. Track down the key personnel responsible for addressing claims disputes. Learn more about Preferred Provider Organization (PPO) and Health Maintenance Organization (HMO) dental plans before discussing the dispute. The HMO dental plan allows you to choose a dentist or group of dentists for your treatment, while the PPO restricts your choice to the list of dentists available in your area. (I THINK THIS IS THE OPPOSITE)

5. Inform the company that you wish to file for a "first step" grievance, which is often referred to as an appeal, a reconsideration, a grievance or a complaint depending on the insurance provider’s definition.

6. Check out organizations that help in resolving dental insurance disputes. There are many peer reviewers in the US who arbitrate in such disputes. Dentists often have mediation experience and they involve aggrieved parties to resolve the dispute amicably.

7. Prepare for a panel hearing, if everything else fails. The committee panel consists of dentists who offer recommendations on the issue through their findings. Such panels are not available in all states; check with your local state agencies.

Tips & Warnings

• Insurance benefits and billing issues are often at the discretion of the insurance companies. You need to understand this before considering a dispute resolution.
• Understand all clauses included in your coverage. You should specifically learn what is excluded and about the expenses for a particular treatment. Get all information about UCR and annual maximum limits.
• Unless absolutely necessary, avoid taking legal recourse as it will cost valuable time and money.

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