Dentaltown December 2019 - 37

No GM = no possible chance of getting CAL; the CAL marked there is just a guess by the
computer. The insurance company can easily assume that the patient has swollen tissue that can
be up to 2mm GM readings, which would make all those 5mm pockets really 3mm CAL. The
term is called "pseudopocketing." Not saying it is right, just saying this is how these claims get
denied. Start marking GMs and you will get far fewer denials, and be able to fight them a lot
better when you do. ■

Practice Whisperer
Member Since: 07/22/11
Post: 9 of 58

8/15/2019

There is clear bone loss and gross subgingival calculus build-up. All they should need is
those X-rays to approve this. Glad I dropped them long time ago. ■

hmdmd
Member Since: 04/22/05
Post: 10 of 58

8/15/2019

I get your point and I realize you are just pointing out the insurance company's rationale for
denying the claim. My thinking is, when this claim was submitted the obvious heavy subgingival calculus, the pocket depths and the radiographic bone loss (although not severe, still present)
should be enough information for an insurance company dealing in good faith to pay this claim.
I guess my post is more of a warning to other dentists of what to expect from United Concordia.
Preauthorize no matter how obvious you may think it is. ■

jcr87
Member Since: 04/04/06
Post: 12 of 58

8/15/2019

But don't you see that is unnecessary? I have not preauthorized an SRP in 10 years, and they
all get paid. You just need to realize insurance companies are not dentists-they don't think like
dentists. They don't give a damn about clinical factors or good faith; they care only about the
data points they want. And in this case, the data points they need is a true CAL, which requires
GMs. The reason for this is because that's how AAP actually defines things ... but in reality, it's
just about they know dentists aren't that smart when it comes to insurance and usually don't
provide it, thereby giving the insurance company an easy way to legitimately deny (according to
state department of insurance).
If you understand what the insurance company wants and can provide it, you will get paid
and you won't have to waste your time with pre-Ds, and you can greatly decrease the [grief]
when you know what they want to see and actually provide it. Many insurance companies aren't
much different in that if they need more claims in a quarter to deny, the ones without GMs on
SRPs are going to be the first ones hit because they are easy targets. ■

Practice Whisperer
Member Since: 07/22/11
Posts: 13 and 15 of 58

8/16/2019

This may be a dumb question, but when measuring GM, you are referring to measuring
recession, right? ■

mcole
Member Since: 01/21/15
Post: 16 of 58

8/16/2019

A lot of people refer to it as "recession," yes. GM is what most softwares label it and it is more
accurate because healthy tissue starts at around -2 GM, meaning 2mm above the CEJ, so in
many cases it isn't recession specifically. ■

Practice Whisperer
Member Since: 07/22/11
Post: 17 of 58

8/16/2019

Thank you for clarifying that. Is there any specific way of recording that helps getting SRP
covered? Like, if there is no recession do you fill in a "0," or is that unnecessary? ■

mcole
Member Since: 01/21/15
Post: 18 of 58

8/16/2019

dentaltown.com \\ DECEMBER 2019

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Dentaltown December 2019

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