How to Deal With Dental Claim Denials
Dental claim denial is a gap that happens between verification and coding. It can lead to surprises and much higher revenue loss.
Each year, hundreds of thousands of patients have dental implants. Although more insurance companies include benefits, coverage varies. Dental implants are covered only when medically necessary. Approval of an implant benefit does not mean individual dental claim benefits will be covered. It could result in dental claim denial.
Dental implants are artificially placed in the bone to act as a tooth root. An implant is then connected to an abutment, from which a crown is placed. A crown is then attached to the abutment to restore the implant. Dental implants can be expensive.
If a claim is deficient in any way, it will be denied before it can be assessed for medical necessity. Sometimes documentation is so lacking that the clinician cannot even evaluate a patient for treatment.
Clinical documentation must include recent diagnostic X-rays, pictures of the area being treated, full charts, and notes on anticipated future treatment. If treatment is not fully explained and documented, the claim may be denied.
Knowing what questions to ask concerning a patient’s insurance plan is critical. Does the patient have implant benefits? What does it actually mean?
There are limits on coverage for implants for teeth lost before the effective date of the policy. Some policies limit the number of missing teeth in a jaw to three. If a patient has more than three missing teeth in a jaw, they may not be eligible for implant benefits, even if coverage is otherwise not restricted.
There may be a time limit after the beginning of coverage before implant benefits are available. Treatment initiated before this time limit may result in the claim being denied.
If implants are placed, some insurance policies will pay for a less expensive option, e.g., a removable partial denture. Given this type of clause, it is appropriate to inform the patient that the implant procedure will not be fully covered.
There are different types of implant crowns and corresponding codes. Coverage is in order; it may still be denied.
Frequent errors include:
Distinguishing between abutment-supported and implant-supported restorations is incorrectly reported. Abutment-supported restorations should include the abutment and crown. An implant-supported restoration includes an integrated abutment and should not be reported.
Implant claim denials occur for numerous reasons, most of which can be prevented. Understanding the claims processing system can help the dental practice improve reimbursements. Explaining the treatment plan and the financial obligations not covered by the plan builds patient trust and eliminates surprise bills.
What other ways can a patient afford dental implants without getting a dental claim denial? Educate the patient regarding other options.
Some organizations provide low-cost dental care and implants. The University of Pennsylvania School of Dental Medicine offers dental implants at a lower price than other dental practices.
Instead of traditional dental plans, some companies offer dental savings plans for an annual membership fee, with services at a discounted rate.
HSA/FSA funds in these tax-exempt accounts can be used for dental implants if they are not for cosmetic reasons.
Just keep in mind the following when considering costs:
Let's say your insurance covers 50% of the cost of a dental implant, your deductible was $100, and the total cost was $2,013.
The insurance portion was $956.50.
You would pay $1,056.50 out-of-pocket.
The total could be much higher if the insurance does not cover procedures to affix a crown to the implant (i.e., placing the abutment) or the crown itself. These procedures and the implant crown could increase the total costs by $1,000 to $2,000.
There are several ways to avoid claim denials for implant-supported restorations, including:
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Some policies cover a part of the expenses involved in implants. Most dental insurance plans have exclusions and limitations. Details of the policy govern coverage benefits.
A claim may be denied because implants are not a covered benefit. The patient may not have completed a waiting period. Lastly, the patient may have reached the annual limit.
Yes, with additional plan documentation, if the case allows, but there are no guarantees.
