PDA Meets with United Concordia
Report of June 12, 2015 meeting with United Concordia
By George Hamm, DDS
On June 16, 2015, four PDA members and I met with representatives of United Concordia. The purpose of the meeting was to discuss claim rejections and processing policies at United Concordia (UC). Rejection of restorations, crowns and Scaling and Root Planing (S&RP) are of particular concern.
Representatives from PDA indicated that they are personally experiencing claim rejections for restorations, crowns and S&RP and they have heard similar complaints from many of their colleagues. They stated that these rejections have exacerbated over the past 18 months or so and that the rejections are more profound than any of the other dental carriers.
By way of background, UC indicated that their dental advisors are responsible for reviewing these claims. All of the advisors are full-time private practitioners who receive an hourly fee for their services with UC. They are not UC employees.
UC representatives stated that their processing guidelines stipulate:
- claims for crowns should be rejected only when a periodontal condition is obvious;
- restorations are only reviewed if a dentist is “under review” for utilization issues;
- S&RP claims are often judgmental, based on Advisors’ professional opinions of bone loss, as stipulated in AAP guidelines. (Copy of AAP guidelines are available.)
UC representatives acknowledged that some of their advisors may be interpreting the guidelines too literally and they will have follow up discussion with them.
They also proffered that they initiated an “Honors Program” 8-10 years ago wherein designated dentists were not subject to any claim review. Rather, all claims were processed and approved. However, when UC reviewed the claims after they had been paid, they found that many dentists in the Honors Program were submitting claims, particularly S&RP claims, at a greater rate than non-Honors Program dentists. Therefore, they dissolved the program, which resulted in claims that had gone through their system without any scrutiny, now being subject to routine review. Consequently, more claims are being rejected.
Further, they mentioned that the ADA is considering a new code that will satisfy procedures done that are more than a routine prophylaxis, but not as severe as S&RP. Although the earliest that this code could be implemented is 2017, all agreed that it could alleviate some of the existing problems.
After it was all said and done, UC indicated that they will be meeting with their advisors in August at which time they will emphasize the need to be reasonable in the interpretation of the processing guidelines. Meanwhile, they will talk with advisors that they know are more conservative than others. Time will tell if the meeting was successful or not. We will be monitoring and following up.
August 17, 2015 Update: Following our meeting with United Concordia, James Bramson, DDS advised PDA that UC reviewed their guidelines with their dental advisors and held a “calibration session” with them. As a result, “…July shows that crown denials for this particular reason were down about 30 percent from what they were when we met.”