Procedure Codes

Back in March I went to the dentist for a routine cleaning. A week or two later I was reimbursed by my dental insurance (after my dentist submitted the claim directly). I noticed that as usual the insurance paid most but not all of the bill but otherwise paid little attention. I went back to the dentist in October for another routine cleaning. This time I paid a bit more attention when my reimbursement check arrived (because coincidentally dental insurance reimbursement rates had recently come up in conversation) and noticed it was more than the earlier check. My first thought was that my insurance company must have raised its reimbursement rates. This was a small part of the explanation but examining the respective explanation of benefits statements showed that most of the difference was because in March I had been reimbursed for procedure code D0190 (screening of a patient) whereas in October I was reimbursed for procedure code D0120 (periodic oral evaluation) which my insurance covers for a larger amount. (In both cases I also was reimbursed for procedure code D1110 (adult cleaning)). So my next thought was that my dentist had coded my claim suboptimally (from the point of view of maximizing insurance reimbursement) but my March bill showed the D0120 code and when I went into the dental office a couple of weeks ago with my bill and the insurance statement of benefits they insisted the insurance company would have received exactly what was on my bill. But they also offered to try and straighten things out. And Monday I duly received an additional reimbursement check from my insurance company.

So what happened? This is a bit puzzling as it seems everything should have been handled by computer with little room for human error given that the original entry into the system was done correctly as it appears it was. It seems unlikely that MetLife is randomly recoding procedures (to reduce reimbursements) and hoping nobody notices. I suppose a short lived computer software bug is the likeliest explanation but who knows. In any case when receiving explanations of medical benefits it seems it can pay to take a moment to compare the procedure codes to those on your bill from your provider.