As a health care provider, interacting with a patient’s insurance company is often not dissimilar to dealing with a toddler. The other day, we submitted an insurance claim for the extraction of tooth #20 on a patient whom we have never treated previously. With the claim, we submitted an xray that clearly showed tooth #20… what was left of it anyway. It was badly broken and more of a tooth root than a whole tooth.
The insurance company (Delta Dental in this case) denied the claim stating that the reason for denial was that their records indicated that the tooth had already been extracted. We then figured some other provider before us must have tried to extract it previously, broke the tooth, and then submitted a claim for the extraction anyway. With that, we submitted a different claim for “removal of a residual tooth root”. The insurance company denied this too. However, they gave the exact same reason as was given in the first denial: Their records indicate that the tooth had already been extracted.
Here’s the thing. Anyone who knows how to read a dental radiograph could tell you that tooth #20 was present on the xray we submitted. Therefore, the insurance company’s records stating that the tooth was removed are clearly inaccurate and any claims examiner who’s looked at this claim (and who isn’t legally blind anyway) would know this. However, the insurance company couldn’t care less about this reality. They also couldn’t care less that the error in their records is clearly not the fault of their subscriber (aka the patient), nor we the provider. So long as they can formulate any argument to deny a claim (poor as the argument may be) they’ll do so.
AND THIS HAPPENS ALL THE TIME. It’s exhausting. They know their arguments are bullshit. But, it’s a war of attrition. Essentially, their strategy is to keep throwing obstacles in the way of a claim being approved. If they keep it up long enough, the patient/provider might ultimately give up and they won’t have to pay.
The real kicker is that all of the efforts on our part to get these claims paid are on behalf of the patients. These arguments do not technically involve the provider as they are between the patient and their insurance company. Legally, we could just demand that the patient pay what their insurance denied and let them wage the war with their insurance. However, few patients are equiped to have such a fight. Worse yet, it is we who these patients typically hold responsible when their insurance pulls this crap. Insurance companies know this and are happy to let us take the heat.
… Because they’re bitches. Period.