Dental Insurance Appeal Letter of the Year

by Hand Up

Have you ever had a medical or dental insurance claim denied?  Did you have someone willing to help you out by appealing to your insurance carrier?  If not, did you try to sort through the complicated language of your benefits coverage in order to appeal to your carrier yourself?

A buddy of mine has a wonderful dentist.  It isn’t just that the guy provides great care and that his office staff is wonderful, but his dentist is a likeable person, too.  And he has a wicked sense of humor.

Case in point is a letter that my friend’s dentist sent to his insurance company to try and get coverage for his teeth cleaning.  The insurer, who shall remain nameless here, refused to pay for his cleaning because it was performed less than six months since the previous cleaning.  In case you don’t have dental insurance and aren’t familiar with their rules, many companies insist that you wait a full six months before having your next cleaning.  If you go in before that, they won’t pay for it.

There is some logic behind such a rule as it limits how many times an individual can benefit from the coverage.  It wouldn’t be fair if we all paid in the same amount in premiums, but you got to get your teeth cleaned three times a year while the rest of us had to be happy with two.

Where it gets unreasonable, however, is when your teeth get cleaned just a day or two before the magic six months has passed.  By not waiting just 48 hours, you are forced to pay a hundred or more bucks!

So, that is exactly what happened to my friend.  He received a letter from his carrier stating that they weren’t going to pay a penny for his $125 cleaning because his appointment was two days too soon.  Before he had a chance to call his dental office, however, they were in touch with him.  They had received the exact same notice, and his dentist wrote the following letter to the insurance carrier.

Not only was the letter funnier than all get out, it was also effective.  The insurer reversed their decision and paid the $125.

Here is what changed their mind:

 

 

May 17, 2012

 

Acme Dental Insurance

1234 All American Drive

Anywhere, USA  01234

 

Re: John Doe              Claim # XXXXXXXXX

 

To Whom It May Concern:

 

I am counting on the fact that you have a good sense of humor!  If not, would you be so kind as to pass along this appeal letter to someone who does?

 

In reviewing the enclosed EOB, I understand that benefits were denied for John’s 5/8/12 Prophylaxis due to “A Frequency Limitation”.  I immediately checked John’s records and realized that the previous Prophylaxis had been performed on 11/10/11.

 

Like you, I thought to myself – “His teeth were cleaned two days too soon!”  Had we provided this Prophylaxis on May 10 instead of May 8, it would have been covered.

 

As I am about to explain to you, however, initial impressions can be deceiving.

 

Now, in a typical year, the number of days between November 10 and May 10 would be 181.  So to meet your Frequency Limitation requirement for coverage, we would have had to wait 181 days after the November Prophylaxis.

 

But 2012 is not a typical year.  It is a Leap Year!  That means that we had actually waited 180 days.  We are only one day, not two days, premature!

 

Ah, but there is more…

 

In reviewing our appointment book, I noted that John’s November 10 visit was at 8:00 am, and his May 8 visit was at 9:00 am.  In truth, we were just 23 hours too soon.

 

By this time, you are probably WAY ahead of me!

 

Yep, like you, I wondered about the scenario in which a patient has his teeth cleaned at 9:00 am on November 10 in, say, American Samoa.  By May 8, he is living in New York City and has his teeth cleaned there.  Now our 23 hour gap is down to 17 hours.

 

Let me be clear about one thing.  I’m not saying that John lived in Samoa or that I practice in Brooklyn, but it does generate an interesting conversation.  Give me a couple of hours and a glass of wine, and I could think of a dozen scenarios that challenge the precise measurement of your Frequency Limitation.

 

For example, do you cover dental care on a cruise ship?  Have you ever had an appeal based on the International Dateline?  Has a dentist ever prepared a tooth on one day and filled it the day before?

 

I apologize for getting off track.  I just ask that you consider making this exception to your rule.  I appreciate the fact that rules are necessary – I have five kids, for goodness sake!  But even I let my daughter skip her math homework the occasional night so that she could watch a televised Norah Jones concert.

 

Please reconsider your denial of benefits for John’s Prophylaxis.  A few hours in the context of six long months is a very short time.  Particularly when you consider the fact that the Earth is gradually slowing in its speed of rotation on its axis.

 

Which gives me an idea for my next appeal letter….

 

Sincerely,

Dr. Clever Sidesplitter

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