What options do I have if I disagree with the insurance plan's payment decision ?

Any time a health care provider disagrees with a health plan’s payment decision, a payment dispute exists, which the health care provider can appeal through the plan’s provider dispute resolution process.

Legislation passed in 2000 requires managed care health plan processes for provider dispute resolution to be “fair, fast and cost effective.” A dispute resolution process that is not fair, fast and cost effective is essentially in violation of state law and the process itself can be challenged. The regulations also require plans to inform providers that they have the right to challenge a claim payment and to explain how providers can initiate a challenge. Again, if a dental plan’s reimbursement is different from the submitted claim, it constitutes a payment dispute and a plan that fails to provide notice that the payment decision can be challenged violates state regulations.

The DMHC regulations that require plans to have a process of provider dispute resolution do not address the nature or format of these appeals. They mainly mandate that each plan establish a process and a time frame within which to consider and decide on payment dispute challenges. Subsequent to the DMHC regulations, a similar provider dispute resolution requirement was placed in the Insurance Code, applying to preferred provider organizations regulated by the Department of Insurance.

However, if a plan decides to uphold its original payment decision, rejecting a challenge you have submitted, you have a right to a second level of appeal. That occurs through the Department of Managed Health Care itself, which has made such filings easy and continues to refine the process. The department has also recently increased its ability to review provider disputes. If you believe a payment was unjustly denied, you must first go through the plan’s provider dispute resolution process, and if the plan dismisses your challenge, file the dispute with the Department of Managed Health Care.

Dentist Problems In Billing Forms With Patients

Common questions & answers with patients insurance collections and dental benefits plans.

What can I do if a patient refuses to pay for what insurance won't cover ?
When the parents are divorced, who should pay for a child's treatment ?
Is it reasonable to check my patient's credit history before I start treatment ?
Can I charge interest for late payments ? If I do so, am I required to notify patients before I start charging interest ?
What notices am I legally required to provide patients to whom I offer third-party financing ?
What if the patient doesn't return for completion of the treatment and the dental plan has already paid for it ?
Can I offer a discount to my patients who pay in full prior to treatment ?
Are there legal problems in giving discounts to family, staff or colleagues ?
If a patient is behind on payments, can I withhold records or stop treatment ?
How do I collect an unpaid balance if the patient is in bankruptcy ?
A patient is owed a refund from overpayment, but I cannot locate the patient to send the refund. What do I do with the funds ?
What do I need to know about working with a collection agency ?
What are the federal and state laws that apply to my collection efforts ?
Is there a statute of limitations for collecting debt ?
Is small claims court an option for collecting unpaid bills ?
What should I do if a patient isn’t satisfied with the quality of treatment and wants a refund ?
Should I use the fee allowed by the plan for each procedure or my own usual, customary and reasonable (UCR) fee ?
Can I waive patient copays ?
Can I establish a discount program in my practice for patients, and what are the legal requirements ?
How soon must I submit a claim in order for it to be considered valid ?
How soon must a dental plan or insurer pay submitted claims ?
What options do I have if I disagree with the insurance plan's payment decision ?
A dental plan is auditing my practice - what does this mean ?
Does an auditor have the authority to access patient records ?
How can a dental office prepare for an announced audit ?
What if the office fails the dental audit?
Are plans required to pay for in-hospital dental treatment ?
Does obtaining a prior authorization from a patient's plan obligate the plan to pay for that treatment ?
Can lab costs be charged on a claim separately from a procedure ?
Must refund demands from dental plans always be paid ?
What should I be aware of when considering contracting with a plan to join its provider network ?
Can I balance bill a Denti-Cal beneficiary for the portion of my bill that wasn't paid by Denti-Cal ?
May I charge a Denti-Cal patient for an alternative procedure that is not a covered benefit of Denti-Cal ?
Must an associate dentist in my office be separately enrolled as a Denti-Cal provider if I am enrolled as a provider ?
What is the best way to obtain information about the treatment, provider participation and payment policies of the Denti-Cal program ?
How and when your practice verifies patient insurance coverage ?
What medical plans will pay for in dental operations ?

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