5 Mistakes to Avoid When Submitting Dental Claims with Insurances

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3D illustration of DENIED stamp title on insurance claim document

Even trivial mistakes in dental claims can lead to their denials and thus causing decreased collections and high accounts receivables. Therefore, the attainment of “clean claims” requires prolific knowledge of the complete procedure and a meticulous approach towards it. 

By understanding and thus avoiding the below mentioned reasons can decrease or even eliminate the dental insurance claim denial ratio. 

1) Insufficient Knowledge of the Process: 

According to a recent study, almost 50 percent of the dental claims get rejected due to insufficient documentation or failure in following the updated protocols related to dental billing and RCM.

Each insurance plan requires a set of specific documents, along with a thorough description of the provided treatment. Additionally, the dental insurance rules standardized by the government undergo several periodic updates and changes. 

Furthermore, codes of insurance claims differ for each treatment. Even a minor difference in treatment requires different code to file its insurance claims. Therefore, coding of the diagnosis demands high accuracy and precision. Additionally, many dental procedures require pre-authorization. Similarly, insurance payers require a proper narrative of the provided treatment, which includes: 

  • clinical condition, 
  • description of performed procedure, 
  • reasons for the requirement of additional time or material, and 
  • other relevant documents viz. for Pre-Auth that comes under the participating provider agreement.

Absence in any such documents leads to claim rejections. 

Thus, to avoid any denials and file clean claims, the person should hold adequate knowledge of the complete revenue management cycle of the dental industry. 

2) Failure in Insurance Verification: 

Insurance verification of the patients prior their scheduled visit to the dental office. Appointment or treatment plays a major role in eliminating any scope of claim rejections. Patient’s insurance verification provides the knowledge of the patients’ background, such as their eligibility, insurance coverage, and active benefits, which eventually affects the planning of their treatment. The procedure re-surfaces various factors such as outdated, terminated or modified insurance policies, incorrect information of the patients, etc. that can further lead to dental claim denial. This procedure also provides a concise information of the complete procedure to the patients, cost bifurcation, and the surplus cost that has to be incurred by them. For dental practitioners, insurance verification ensures successful insurance billing, clean claim submission, and low turnaround time for claim reimbursement. 

The procedure requires thorough verification of the patient’s background and insurance policy, as even a small information gap can drastically increase the chances of claim denial. 

3) Precipitous Claims: 

Insurance claims, when not submitted on deadlines, can lead to permanent revenue loss. However, claim submission done hastily in order to meet the deadline is amongst the major causes of claim denials. Errors such as missing X-rays, incorrect date of service, coding errors, and other supporting documents become unavoidable in claims when they are filed in a precipitous manner. 

In order to avoid errors, one has to submit the claims right after the treatment is rendered to the patients. The process should be standardized to eliminate any scope of mistakes and information gap. 

4) Ineligible Claims: 

There are several cases of insurance claims that could be ineligible because of some technicalities in the insurance policy. Some of these technicalities are mentioned below:

  • Least Expensive Alternative: Many dental insurance companies imply that the patient and dental practitioner should opt for the least expensive alternative of the treatment. Failure in following the same causes claim denials. To avoid such complications, a detailed narrative of the treatment supported by a valid reason should be attached to the claim. 
  • Pre-enrollment health condition: Another limitation in insurance claims that can cause claim rejection is if the claim is regarding a condition that existed before the patient was enrolled in the policy. This situation can be avoided by attaching a certificate of prior creditable coverage. Such certificates serve as a verification that the patient has been taking continuous treatment for the condition, covered by the prior/another insurance policy, and thus allows a waiver for the waiting period between the treatments. 
  • Frequency: Treatment frequency is another factor that can contribute to the denial of claims. Insurance policies standardize the frequency of certain treatments that a patient can benefit from. Thus, keeping track of the number and types of treatments benefitted by the patient holds a great deal of importance when dealing with insurance claims. 

5) Failure in Claim Monitoring and Denial Management: 

Revenue management cycle is a long process that requires persistent efforts, continuous claim’s status monitoring, multiple follow-ups, and denial appeals to ensure the continuous revenue generation. It demands in-depth knowledge as well as dedicated time to manage the complete procedure. Failure in managing any of the steps can cause severe hindrances in claim reimbursement, even in revenue loss. 

How to avoid any of these mistakes from happening first hand?
The eminent option to avoid such mistakes is to rely on experts to handle the complete revenue management cycle. Outsourcing a dental billing company which can handle the end to end procedure, including billing requirements, dental insurance verification, and patient statement, can make this process error-free bolstering the revenue generation for your practice.