Question

It's April and Mrs. Unlucky has broken a tooth. You determine that it needs RCT and refer her for the endodontic treatment since the canal is quite curved and calcified. She returns and you do a core build-up and crown. Her insurance only pays $100 of your $1500 total fee. What is the most likely reason?

Option 1: Lack of preauthorization
Option 2: Inadequate documentation
Option 3: Low coverage limit
Option 4: Fee exceeding UCR (Usual, Customary, and Reasonable)

Answer 1

The most likely reason is low coverage limit.

Step-by-step explanation:

The most likely reason why Mrs. Unlucky's insurance only pays $100 of the $1500 fee for her RCT, core build-up, and crown is Option 3: Low coverage limit. A low coverage limit refers to the maximum amount the insurance will pay for a specific treatment, and in this case, $100 is the limit set by the insurance.

Answer 2

The most likely reason insurance paid only $100 of a $1500 fee for endodontic treatment is the fee exceeding the Usual, Customary, and Reasonable (UCR) rates. Lack of preauthorization, inadequate documentation, and low coverage limit are also possible reasons, but the UCR issue is the most probable (option 4).

Step-by-step explanation:

If Mrs. Unlucky's insurance only pays $100 of the $1500 total fee for the endodontic treatment, the most likely reason for this could be Option 4: the fee exceeding the Usual, Customary, and Reasonable (UCR) rates. Insurance companies often have a UCR rate, which is the amount they are willing to pay for a particular service in a specific region. If a provider's fee is higher than this rate, the insurance may not cover the entire cost, leaving the patient with more significant out-of-pocket expenses.

Another possible reason could be Option 1: Lack of preauthorization. Insurance companies sometimes require preauthorization for certain treatments to ensure they are necessary. Without this preauthorization, they may not cover the costs. Option 2, Inadequate documentation, refers to the need for proper documentation to justify the treatment, and Option 3, Low coverage limit, implies that the patient has exceeded their coverage limit for the year. However, based on the given scenario, the fee exceeding UCR seems to be the most plausible explanation.

Hence, the answer is option 4.