Seeking Reimbursement for Non-delivered Cases

August 2019
Workers Compensation

Most practices have cases that have not been delivered because of patient non-compliance. For whatever reason, the patient has not returned for the delivery of the prosthesis, occlusal guard, crown, retainer, orthodontic aligners, etc. and the plan has established that the incurred liability date is the date of delivery. The practice has spent a significant amount of time, effort, and expense on that service and yet the patient cannot or will not return to have the service finished. What can you do? Can you get paid for what has been done when the plan establishes that the service can only be billed when the service has been completed?

The answer is, maybe — for at least part of the services provided to date.

So, how can you be reimbursed for those cases gathering dust in the cabinets in the lab?

It is suggested that before beginning this process, let three to six months pass while continuing to encourage the patient to return for the delivery of the item. Make handwritten notations in the clinical record of all attempts to complete treatment, including the patient’s failure to schedule appointments, as well as the number of times the patient cancels appointments or just fails to show up. If the practice has not been doing this in the past, it should begin to document patient compliance in the clinical record. This information would include the dates of cancelled or failed appointments. Most practice management software platforms track missed and cancelled appointments; however, that information in most systems can be modified at will and therefore does not constitute legal documentation. (Any information contained in the practice management software that can be modified is like a clinical record that is made in pencil and therefore does not constitute “legal” documentation.)

Provide the payer with the following information:

  • A list of the attempts the practice has made to contact the patient to schedule them to complete treatment
  • A list of the appointment days and times with an estimate of the associated chair time when the patient did not come into the office.
  • A copy of the clinical notes that establish what was done during each of the visits
  • A copy of the lab prescription(s) that will establish what item was fabricated by the lab and the number of try ins, modifications, and steps that were involved in the process
  • A copy of the bill from the lab that outlines the charges incurred in the fabrication of the item

With all this supporting information, send a request to the patient’s plan for consideration of reimbursement based on the practice’s good-faith efforts to complete treatment and the patient’s noncompliance with these efforts.

Many plans will consider the request and provide at least partial reimbursement for the practice’s efforts to complete the treatment. Some plans will pay lab expenses and others will reimburse the entire amount due, less the cementation fee for a crown or an adjustment fee for a removable prosthesis.

Remember, “Nothing ventured, nothing gained.” Partial reimbursement is better than no reimbursement at all.

The best protocol is to always collect the patient’s deductible and estimated copayment at the start of treatment. This will result in better patient compliance.

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Fixed Partial Denture Repair

A single cast metal crown restoration that is retained, supported and stablized by an abutment on an implant; may be screw retained or cemented.

NOTE: May be orthodontic related