Dental Professionals recommend treatment according to the patient’s need. However, these  may not be the case in various scenarios. Patients rely on dental insurance to cover their  treatment, which has been recommended by dentists. However, clauses like “Alternate  Benefit” can make amends in the dentist’s recommended treatment as well as covered  treatments for the patients. 

Alternate Benefit Clause: 

Alternate Benefit, which is also known as the “Least Expensive Alternate Treatment Clause  (LEAT)", states that when multiple treatment options are available for a patient’s treatment,  the dental claim would be viable on the least expensive treatment. Insurance companies  evaluate the diagnosis and recommended treatment of the dental professional and approve  claims only for treatments that come under LEAT. As per American Dental Association  guidelines, insurance companies have to educate the enrollee about the clause, coverage limits,  and other protocols about the insurance plan and LEAT. Additionally, the name and  qualifications of the person who will be responsible for evaluating the treatment of the dental  professional on the behalf of the insurance company have to be shared with the dentists. The  basis of the determination of the approved treatment that would be covered by the insurance  plan has also to be shared with the dental professionals. If the dentist or the patient decides to  go with the expensive treatment, the insurance company will pay the allowable amount under  LEAT, and the difference would be charged as an out of pocket cost by the patient. 

Intentions behind Alternate Benefit Clause are not dictating the treatment plans but increasing  the affordability of the insurance plans. LEAT allows less funding required by the insurance  companies, hence allowing more affordable insurance plans to a large number of people. 

The treatment that comes under LEAT varies with the dental plan. Major downgrades are  applied over composite fillings which are alternate benefitted to amalgams; posterior crowns  are alternate benefitted to all-metal crowns, and crowns are alternate benefitted to large  fillings. Additionally, under LEAT, insurance companies provide less coverage for expensive  treatments such as root canals, crowns, and bridges. Along with LEAT, dental coverage also  depends upon annual maximums and lifetime maximums. 

Predetermination of benefits: 

Prior to the treatment, insurance companies require predetermination of benefits, which  includes recommended treatment, the basis of recommendation, an x-ray of the patient, and  treatment codes. This documentation is then evaluated by the insurance companies and  provides treatment alternates as well as reimbursement eligibility details. 

Insurance Eligibility Verification: 

The important step to ensure accurate submission of predetermination of benefits is Insurance  Eligibility Verification. Accurate submission of supporting documents and codes are necessary  to claim approval by the dental insurance companies. However, a multitude of dental insurance 

companies and their protocols requires experts to deal with such procedures. The person  dealing with insurance eligibility needs to be well versed with the alternate benefit clause of  each insurance company along with the dental industry and various treatment codes.  Submitting predetermination of benefits requires prolific knowledge as well as dedicated time  to achieve accuracy. Any error or mistake insurance eligibility verification process can lead to  claim denials, treatment downgrade, payment delays, and faulted RCM process. The person  responsible for managing the Insurance Eligibility Verification process needs to deal with co payments, co-insurance, deductibles, patients’ plan eligibility and status, payable benefits,  exclusions, insurance coverage detail, treatment codes, etc. 

Handling above mentioned tasks can be highly strenuous for a dental professional. Even though  hiring an expert can seem a viable option, it could be expensive and riskier than outsourcing  similar services from a dental billing company. A hired employee will be the responsibility of the  dental professional, and the process will still be prone to errors and mistakes. On the other  hand, outsourcing such services can be highly beneficial. Dental billing companies are highly  trained experts who possess profound knowledge of their domains. Each process is separately  handled by such experts and documentation is passed through various channels that ensure  high accuracy. Additionally, any committed error is the responsibility of the company rather  than the dental professional. Considering all of these benefits, 90% of the American dental  professionals are outsourcing these services from companies like Capline Dental. With years of  experience in handling such processes, Capline Dental Services has won the trust of thousands  of dental professionals by providing eminent services with the best track record of claim  approvals. 

The amount left after you have paid your deductible and your insurance plan has paid for the medical services you received as per the terms & conditions of your policy is known as Balance Billing. In other words, it’s the difference between the total cost of the services you are charged for and the amount your insurance plan pays. 

How Balance Billing works?

Let’s assume that you go to the doctor and get treatment. At the time of receiving the treatment, you pay your deductible and your insurance plan supposedly covers the rest. Now, as per the process, you have paid all your bills for the treatment. But months later, you receive a bill from your doctor for the amount your insurance plan didn’t cover. And, this bill is the Balance Billing. 

Although it seems like you have been charged extra as per the terms used, you are simply paying for the services you received. It’s just the amount that your plan didn’t cover!

A balance bill can be quite triggering for a patient, especially if it’s a large amount. However, you need not worry as your healthcare provider can help you understand the same. Let’s know what healthcare professionals can do to make sure that the patients aren’t confused about the balance billing!    

What healthcare providers can do?

While balance billing may come as a surprise for patients, especially when they are unaware of it, healthcare providers count on it as far as revenue is concerned. 

• Being a medical services provider, you need to make sure that the patients’ care always stays on top so that they do not care whether you fall under their insurance plan’s network or not! In that case, even if there are stances of balance billing, patients may not care much about it as they are getting the desired services at their comfort.    
• Healthcare providers need to make sure that patients are well informed about the balance billing. It will not just improve their trust in you, but inspire them to continue with your medical services instead of giving much importance to balance billing. 

Although no patient would like to experience balance billing as nobody wishes to pay extra, if your patients are well informed at the time when they are taking your services, it will solidify their trust in you as their medical services provider. 

What can patients do?

Patients should not confuse balance billing with other billing and insurance terms such as deductible, copays, and coinsurance. Knowing these terms would help them understand the concept of balance billing better. 

• Deductible - The ‘minimum’ amount you need to pay out-of-pocket to your healthcare provider before your insurance policy starts paying for your treatments is known as Deductible.
• Copay - The fixed amount you directly pay to your healthcare provider on every visit, regardless of the treatment you receive is called a copay.
• Coinsurance - The cost that remains after your insurance policy pays for your treatment as per the policy’s terms & conditions is called coinsurance. 

When do you receive Balance Billing?

Balance billing usually does not happen with in-network healthcare providers as the insurance company takes care of the bills and the patient is already aware of the charges. It generally happens when an out-of-network healthcare provider bills a patient for the services that are not covered by his/her insurance plan. The patient may not be aware that the services s/he has received are out-of-network even though s/he received it at an in-network healthcare provider.

Reasons when you are likely to get balance billing:

1. Visiting an in-network healthcare provider and receiving service/s that are not covered by your insurance policy lead to balance billing.
2. Visiting an out-of-network provider and the provider bills you for the amount that your insurance company did not pay.
3. When an in-network provider moves out-of-network of your insurance plan and you take services without knowing the provider’s network status. 
4. The doctor that treats you at your in-network hospital chooses to no longer participate in your insurance plan’s network. 

FAQs

There are some general questions asked by patients regarding the balance billing. Let’s take a look at some of them.

1. Is balance billing legal?

Ans. A medical provider has the right to bill you for any amount that is not paid by your insurance. As a patient, you should be aware of all the costs that your insurance plan covers after paying your deductible.

2. How can I not receive balance billing?

Ans. The healthcare providers will not charge you unnecessarily for any service that’s been paid and covered by your insurance. However, if you wish not to receive any balance bills, you need to stay updated with your insurance plan. Having complete knowledge about your insurance policy will allow you to know the list of in-network healthcare providers and the list of services covered under it. So, when you know that you are going to an in-network or out-of-network healthcare provider and whether the services you need are covered by your insurance plan or not, you are unlikely to get a balance bill.

The other best way to avoid it simply by asking your healthcare provider upfront whenever you go for a treatment. You can ask whether a particular doctor who is attending you is in-network or not and the services you need are covered by your plan or not.

3. Do all treatments have or can fetch balance billing?

Ans. A healthcare provider cannot bill you for medically necessary treatments. However, if you have taken any medically unnecessary treatment, the provider may bill you for it as insurance generally does not cover medically unnecessary treatments. 

Payment Posting, also called cash posting, plays a vital role in the revenue cycle. It has the power to maximize your revenue if executed properly. It’s significantly important for your practice to have a payment posting team that can track and analyze insurance payments from EOBs, ERAs, patient payments, etc.

Placing an effective and efficient payment posting system in place will allow you to track and improve your RCM. Payment posting helps in finding payer problems such as denials, prior authorization, and non-covered services and can be addressed timely by the billing staff. It helps to make your dental billing process more efficient which is directly proportional to improved revenue.  

Terms used in Payment Posting

Before knowing about the payment posting in detail, it’s important to know the relevant terms such as EOB, ERA, Patient Responsibility, etc. Knowing these terms will allow you to understand payment posting better. 

• EOB: Explanation of Benefits, also known as Explanation of Review (EOR) is a document that explains the entire claim process to the dental practice and the patient. 
• ERA: The electronic version of EOB is known as ERA (Electronic Remittance Advice).  It’s the explanation of the insurance processing sent to the practice electronically.
• Patient Responsibility: It’s the amount that a patient must pay to the dental practitioner.  

Process of Payment Posting

• Payment posting is done either manually or electronically (auto) after the claim settlement from the insurance company, EOB/ERA is sent to the healthcare provider, the dental practitioner in this case, and the insured (the patient) towards the payment of a claim. 
• The payment posting team analyses, the patient’s insurance denial, patient responsibility, the EOB that contains the payer's name & address patient’s name, the dental practice’s name & address, the claim received date, claim number, payment or denial date, policy identification number, date of service, dental procedure code, and billed amount.

In case the claim is paid, EOB would also have the following details:

• Allowed amount i.e. an amount the insurer finds fair for specific services or procedures. The allowed amount combines the paid amount and patient responsibility. 
• Paid amount i.e. the amount paid by the insurer minus patient responsibility. 
• Patient responsibility i.e. the balance percentage of compensation that the patient or his/her secondary insurance (if applicable) needs to pay as per the policy with the insurance company. 
• Write off the amount i.e. the amount waived off by the provider. In simple words, it’s the billed amount minus the allowed amount. 
• Cheque, cheque date, EFT, EFT date.

In case the claim is denied, EOB would also include a denial code and reason. 

• The payment posting team accounts for the payment received from the insurer against the claims submitted for the dental services provided. The process includes identifying the patient accounts, procedure, billed amount, paid amount, allowed amount, write-off amount, etc.
• The team, then, posts the payments to the respective patient’s accounts against that specific claim to settle it. If the patient is not able to pay as per the statement provided to him/her or makes no attempts to pay after multiple follow-ups, the process goes to collections.

A dental practice with accurate payment posting is likely to register better revenue. When issues like denials, mismatch of payments received from the insurer, patient payments, etc. are identified and resolved at the front line, it will smooth the entire dental billing process and your practice will register a better cash flow.

PMS or practice management softwares play a pivotal role in dental billing. It helps you to build and carry on with an effective RCM, which eventually reduces denials at providers’ end as well. Beyond everything, the comfort of patients is paramount. You need to look for the right solution if they are unhappy or unsatisfied with the billing. That’s why, before choosing the right dental billing tool or software for your practice, you need to consider several factors.

Let’s understand the various points you should consider before opting for dental billing software.

1. The Cost

Many billing software solutions provide low start-up costs, but instead, an exorbitant monthly fee is paid that could end up being more than your practice can manage. Likewise, free dental billing software solutions are available, but many of these impose restrictions on functionality or time-of-use. To overcome these barriers, search for a software solution that provides free, unrestricted access for functionality while allowing you the opportunity to expand as the practice expands into an enterprise-level solution.

1. Features

Once it comes to functionality that dental billing software provides, the practice will need to consider not just its current needs, but also its potential needs. Remember that you're going to get a billing system that can manage both digital and paper claims, dedicated customer service, and safe cloud data access and backup. These variables can make a big difference in the ability to sustain your practice.

1. Accessibility across platforms and devices

You want to find a dental billing solution that provides compatibility across a variety of operating systems and devices, including desktops, notebooks, smartphones, and tablet PCs. You may also want to look for a product that provides additional benefits to your employees, such as online webinar training to work at the highest level of productivity.

1. The Software Provider

How long has the software company been in business is also an important factor to consider before finalizing a dental billing software for your practices. Longevity is a major factor here. Pick a business that has a strong industry track record. The longer it's been around, the more likely it will function better for you.

1. Support

You're going to want a communicative dental billing partner that not just takes care of your billing but lands considerable support to your practice. Many businesses have software that allows organizations to track their sales process, allegations, and denials on a regular basis. You'll want to make sure that your dental billing provider is attentive and supportive when something goes wrong.

1. Flexibility to integrate with other software applications 

Another important factor to consider is if the PMS you are looking for could be integrated with other softwares and applications. As if the PMS has the features of inbuilt EHR or online patient statement applications, then can it be integrated with the other softwares?

1. Specialty Business practice 

If you conduct a general practice, you'll have fewer specific billing concerns than many specialty practices. To ensure the program fits with your specific specialty or subspecialty, check with the supplier. This is worth checking out because even if you have a general practice, you can one day expand your business with specialties.

1. Payment Recall 

Does this supplier of dental billing software provide a simple and comfortable system for reminding patients of payments? To avoid ruffling feathers, this should be handled with the utmost politeness and diplomacy. If you're running a general practice or being in charge of a specialty, finding the right supplier of dental billing software will help you boost the cash flow and thus RCM.

1. Engaging patients 

This is also a dental billing program that will keep the patients in the loop and deal with overdue accounts. There are dental billing services that send their statements directly to patients, and if necessary transfer unpaid accounts to collection agencies. Many phone calls cover dental billing systems and even answer patient concerns. Some firms even offer a portal for patients for direct online access.

1. Employee scale 

It’s a crucial factor to consider while selecting the software provider. How many people are working at the company? It's best to go with one that has a variety of workers with expertise and knowledge in various dental billing sectors. This helps the firm respond better to billing surges in between quieter periods.

It takes a lot of things to consider while opting a dental billing software. Do not hurry as it’s a crucial decision for your practice. Make sure the provider is responsive and the software is designed for regular updations to meet the changing billing requirements.

Timely claim submission and approval is one of the top priorities of healthcare professionals involved in dental practices. What makes it a top priority for dental practitioners is its contribution to revenue generation. 

As the world is living under COVID-19 scare and industries across the globe are working towards repairing the fallen economy, dental practitioners also need to make sure that their revenue cycle keeps moving smoothly. 

Claim Submission plays a pivotal role in maintaining and improving revenue cycle outcomes, but the process of claim submission and approval is not as easy as it sounds. Even a slightest mistake in the patient’s details or dental codes can result in claim denial or delay. 

To keep the revenue running, dental professionals need to focus on the reasons that can cause claim denial or delay in the claim approval process. 

This article will talk about the 5 of such most important reasons for claims denial and delay, and the measures to be taken by the dental practitioners to avoid them. 

1. Incorrect or wrong information – While sending a claim for approval, it is vital for intake staff to verify all the details of a patient. Sending wrong information in such cases becomes the first reason behind the claim denial. During registration of a patient, make sure that all the details are cross-checked. Creating a list of common mistakes, especially while doing insurance verification, such as generally misspelled names, commonly missed fields in the form, etc. It might consume a bit more time but it will definitely reduce all the chances of claims denial. 
2. Incorrect or missing Billing Codes – Specifications are important when it comes to billing codes. Invalid, incomplete, or erroneous codes will directly result in claim denial. Billing staff or coding specialists should be extremely careful while entering codes. Even the slightest mistake in medical codes can postpone or deny claim approval. 
3. Unauthorized claims – There are many dental services that require pre-authorization. Insurance providers are likely to decline or deny any claim sent to them without proper or prior authorization. Categorize these dental services in advance and submit the claims accordingly. 
4. Late submission – The term is self-explanatory. Any claim, if submitted late, will obviously be denied even if it has all the correct details and medical codes. For timely claim submission, keeping a track of each patient’s deadlines is important. Make sure not to miss them to avoid any reason that can cause claim delay or denial.  
5. Credentialing – It’s a crucial factor. Dental practitioners need to be credentialed with insurance providers. And if they are not, getting claim approvals does not come easy. It’s essential for dental practitioners to be credentialed with the insurance providers, not just one but with other insurance providers as well. 

Apart from these reasons, there are some other common reasons as well for claim denial and delay. Let’s take a look at them.

• A claim submitted with expired health insurance will automatically be denied. Make sure to check the validity of the insurance before submitting a claim. 
• Some insurance companies have the policy to provide only one service in a day. If the claim is submitted for two or more services and the provider complies with this policy, the claim is likely to be denied.

Top 5 Ways to Improve the Cash Flow of Your Dental Practice

A healthy cash flow is like blood in the veins for a dental practice. However, most of the dental practices have to deal with bottlenecks that reduce efficiency and hinder the growth of the practice. The biggest threat to a dental practice’s long-term success is not a lack of profit, it’s a lack of cash flow. Though the providers often try to plug the loopholes, there might still be that slight room for improvement or a better way of handling things that does wonders with the overall profitability of the practice. It’s imperative that time be given to think as to how you can increase the efficiency and eliminate the bottlenecks in the way you are currently handling the workflow. This article deals with issues that might be affecting your efficiency as a dental provider and are worthy of being given a read even if you think things are under control.

1) Effectively coordinating with patients to keep track of patient appointments and verifying patients’ insurance eligibility well in time

Most practices struggle with a true scheduling system with synchronous steps and clear guidelines for patient appointments that the front-desk staff follows. Practices just try to “fill in the holes”. This approach hurts the cash flow the most. Often, patients who come to dentists for a visit, complain about improper communication of appointment times, delay in service and incomplete information being provided to them about their share amount they have to bear for the service in the overall cost of a dental procedure. All these issues have a common cause and that is mismanagement or inefficient management of the patient appointments and insurance eligibility at the office. Often, the staff at the dental office struggles with keeping up with the timely execution of these important tasks besides taking care of routine operational tasks at the office. This aspect needs to be well thought about and needs proper and expert execution as it has maximum impact on the cash coming into your practice. A solution for this is to obtain and store data of each patient in a dental software. All the relevant information for a particular patient should be fetched by an initial phone call and entered in a patient file well before the actual appointment. Providers can take the assistance of reliable dental billing companies for efficient handling of this process.

2) Implementing measures to assist the office staff in better deliverance of operational tasks

Once the issues with the scheduling system and patient eligibility verifications have been dealt with, the other area to focus on is to improve the execution of the operational tasks such as front desk activities, systems to facilitate more efficient performance of dental assistants and hygienists, patient management on the office floor, keeping a check on the ambience and office decor, overall cleanliness of the office, and so on. These are some of the aspects that impact the contentment and satisfaction of patients after a visit to your dental office. Often, because of overburden of work and little time for these routine works, these things are ignored and leave a dent on your service delivery.

3) Regularly scrutinizing the cash-flow statement of your practice

We have discussed how important it is to optimize the execution of activities at your dental practice. However, it’s important to keep a note of and regularly scrutinizing your cash-flow statements. Even if you have outsourced the billing services to dental billing company, you should always prefer a dental billing company which provides you with timely reports on the overall health and performance of your practice on key parameters. You should know where your practice financially stands at all times. Having a clear estimation of incomes and expenses puts you in a comfortable position  to deal with any unexpected shortfall.

4) Keeping updated about the changing guidelines and policies of insurance companies for insurance plans

Insurance companies can severely affect your cash flow and cripple your profit margins. Dental practices have to deal with plans of various insurances and with policies and guidelines for plans changing very frequently, inaccurate claims filing becomes a major cause for claim denials. It becomes one of the major factors in determining if you get paid for the services rendered. So, you have to keep a check on the updates and ensure that before you provide a service to patients, you carefully calculate the patient portion of the payment and submit accurate claims with the insurances.

5) Managing a reserve fund for your practice

Keeping updated about the overall cash flow of your practice helps you keep ahead of the financial exigencies all the time. However, sometimes we have to deal with situations which are out of our hands like the current situation of Covid- 19 which has severely affected the cash flow of dental practices across the country. So, you should start to put money away for a rainy day, kind of a reserve where you put a certain amount of money every month to help you during any financial difficulty that might arise. This reserve can help your practice get through tough periods of slow revenue and help you cover employee salaries, order equipment for procedures, or invest in growth opportunities. This step might be the most difficult to follow but could go a long way in providing the financial stability to your practice.

Healthy cash flow is the most important part of any practice. Irregular cash flow poses difficulties in every aspect for practices. The ideas suggested in this article may not end all your issues at one go, but they can go a long way in ensuring that every aspect of your practice’s cash flow and practice management is dealt with utmost efficiency and that your practice gets poised for higher growth.

You must be wondering why an article that is meant to talk about whether you are getting the trials of dental services or not before opting for them is ESSENTIAL TO DISCUSS? There is a sheer importance of trials of services before you can pick the best one as per your own requirements. So, if you work in the dental industry and you are either outsourcing or planning to outsource dental services, the question for you should be – Are you getting trials of dental services before opting? 

Why does this question matter so much? What is its importance? It seems like a general question. This piece of information will tell you that it’s not! Let’s start by asking yourselves a question. Do you want to be a dental practitioner who spends his/her time on the patient’s billing rather than the patient’s care? Definitely not! You will always want to be a dental professional who chooses the latter - Patients’ care & satisfaction. 

As a dental professional, it’s entirely possible that your intentions and your practice keep a patient’s care on top, but the way you operate your healthcare business may or may not give you that result. You might want to think, why? Simply, because you may have outsourced your dental services to someone without taking a trial. You may have done it without knowing how it’s going to impact your practice.  

Why trial of Dental Services is important?

The question of taking a trial comes into existence only when you decide to outsource a dental service. First, decide which dental service your dental practice requires, i.e. Credentialing, Insurance Verification, Billing & Collection or/and AR follow-ups. Secondly, choose a dental service provider. You might want to communicate with a few before finalizing one. Post that, understand all the nuances of that particular service from your dental service provider about its operations and positive impacts on your practice.  

Building Mutual Trust – Taking a trial of required dental services creates a mutual trust between you and the dental service provider. You trust them with your business. So, it’s important to build that trust before starting working together. 

If you are opting for multiple dental services, it would be great if you get trials of all the services. Make sure you communicate well with your dental service provider to get trials of all dental services before signing any contract or agreement of starting the services. 

Positive impacts of taking dental service/s trial

1. More time for practice - When you decide to outsource dental services, it’s simply because you want the professionals to take care of the areas that are not related to the core of dental practices such as billing, patient statements, insurance verification, claims, dental credentialing, etc. It gives you more time for your dental practice. If you have opted for a dental service without a trial, you may not know or you may not be able to anticipate its impact on your dental practice. Although you can always discontinue a dental service if you don’t see its fruitful. Getting a trial not just gives you a strong reason to trust the agency providing dental services but it also allows you to focus on the core aspects of your practice at the same time. 
2. Timely delivery – While you are busy caring for your patients, you need not worry about their bills, statements, revenue cycle or denial management, etc. It would be possible because everything will be handled and delivered on time to your patients by your trusted dental services provider. 
3. In-house operations – Apart from achieving revenue goals, your target behind outsourcing dental services would be to improve in-house operations that are essentially related to your dental practice. You will only have a core team of professionals (dental assistants, surgeons, front office executives, cleaning, and other staff) in your dental office as long as you have outsourced other dental services to a trusted dental services provider. Thus, it’s a must to take a trial of dental services so that you can entirely trust the service provider. It will help you proportionally improve your in-house operations eventually. 
4. Satisfied customers – Taking a trial plays a crucial role in creating happy and satisfied customers.

Being a dental practitioner means patients will be trusting you with their dental health. Providing them the dental services they deserve is your responsibility. So, opting to outsource your dental service only after taking a trial, becomes by default mandatory for - 

• Timely delivery of your patients’ bills & statements.
• Streamlining your core dental business and practice
• Reducing pendency and increasing efficiency of your RCM cycle.
• Ensuring satisfaction of your clients’ and thus prosperity of your business.

Dental insurance services including verification, claim submission and approval, are a game-changer, when it comes to the satisfaction of dental patients. That’s the reason a lot of dental practitioners choose to outsource dental billing and insurance services. However, it’s not always an easy job for dental services providers to complete the claim submission & approval process. One of the most recurring problems among denial management scenarios, for dental billing and insurance services experts is - “claim not on file” status. The status not only just halts the claim submission and approval process, but also makes a patient wait longer than usual to get the approval for the claim. It’s a problem not just for dental services providers and dental practitioners but for patients also. Let the article guide what exactly needs to be done when “claim not on file” happens?

It’s been an amazing experience for both patients and dental services providers since the introduction of electronic claim submission. The mechanism saves time & effort and the rate of claim approvals is also quite high. Patients get timely approvals and they go home post treatment happily. However, many insurances are still not willing to participate in the electronic system which causes the “claim not on file” issue. The issue seems to help the insurance companies delay the claim payment. 

The cause for - Claim not on file issue:

Billing and insurance experts send clean claims to the insurance company. When the claim is not resolved for over 30 days, the experts contact the insurance company to find out the reason behind the same. The question they have is, “why is the claim amount not paid yet?” And, the usual reply they get from the insurance company representatives is, “Your claim is not on file.” This usually happens when the claims are required to be mailed because the insurance is a non-electronic payer. 

Mailing claims always create some sort of problem. Sometimes, claim files are not received or sometimes misplaced. This either misplaces the patient’s information or it doesn’t reach the right address. Whatever is the case, the patient has to wait and the dental services provider needs to put-in extra efforts to bring the claim approval process back on track. So, it becomes a responsibility for both dental practitioners and dental services providers to make sure that the problem does not occur very often. And, if it does, they should know the exact solution to it.  

Solution to - Caim not on file: 

As a dental billing and insurance expert, you must be aware of certain things before you start resolving the issue. As soon as you get the “claim not on file” status, you need to verify the mail address of claim, eligibility status, filing period, fax number, doctor’s referral letter, date limit, whom to fax the claim, and fax number. 

1. The solution to the problems begins with the verification of the patient’s information with what insurance has on the file. If they haven’t received the claim file or it has been sent to some other address, it needs to be re-submitted. Verify the mailing address before doing that. 
2. Second, the claim needs to be faxed to a supervisor. Verify the fax number first before faxing the claim.  
3. Always wait until the fax is received or you get a supervisor's contact information.  
4. Also, check the patient’s eligibility status to verify the entitlement on the DOS. You should also be aware of the filing limit for the claim. 
5. To avoid timely filing issues, get the claim on file via fax first.
6. Now, do a follow up in a few days and submit the supporting documentation to the supervisor via mail. 

Professional follow-ups with the insurance company and timely submission of a claim with thorough verification of patient’s details can remove this one of the many denial management scenarios, “claim not on file.” The lesser the issues with claim approvals, the happier the patients would be!

Dental offices in Texas are now open with additional safety protocols for patients. All these measures have been taken after following new guidelines to ensure that patients get the required treatment safely amid COVID-19. Dentists are exercising independent professional judgment to ensure that patients in need of dental emergencies in Texas, do not get deprived of the required treatment, when they arrive at offices. Our dental offices in Texas are also ensuring the availability of personal protective equipment and are diligently following COVID-19 workplace safety guidelines in dental offices, to protect the health of patients, dentists, and other staff members all together.

A set of new guidelines will be followed with respect to the waiting area, office reception, screening questions, removal of high-touch items like magazines, newspapers & toys, the number of patients allowed to accompany a patient, and others. Our offices have made these new guidelines simple and convenient for you so that care and protection from coronavirus can both go hand in hand.

Scheduling dental appointments amid COVID-19 is now not only possible but also safe in Texas. You just need to be aware of the following aspects when your next visit gets scheduled.

Reporting emergencies to your dentist amid COVID-19

If you or any of your family members are experiencing pain or discomfort in their gums or teeth, do not hesitate to report your dental emergency to your dentist. The office staff will assess the situation and will advise you accordingly or will ask you to meet your dentist on a priority basis. Uncontrolled bleeding from the gums, cellulitis, swelling of the mouth are some of the conditions that may be judged by your dentist as an emergency. Getting care for dental emergencies during the coronavirus pandemic is possible now in Texas. We have adopted new safety protocols to treat your emergencies while protecting you and your near ones from getting exposed to coronavirus when you visit us.

What may be considered a dental emergency?

Any condition, which when left untreated has the potential to affect your overall health, can be considered as an emergency by your dentist. The professionals will use their experience to evaluate whether the symptoms exhibited constitute an emergency or not, and will accordingly recommend and suggest a treatment.

Scheduling appointments amid COVID-19 

If you already have a pre-scheduled visit for a routine cleaning or for braces tightening with your orthodontist, you will get a confirmation call from the dental office at least a day before your appointment is scheduled for.  In other cases, when you need to fix an appointment for an emergency such as falling off the crown or breaking of the denture, inform them immediately about your situation. Your dentist will evaluate your situation and may allow you to visit one of the dental offices in Texas on a priority basis so that you can be kept out of the emergency room.

Screening of your health before an appointment

A day before your appointment, you will receive a call from the office staff who may have a set of screening questionnaires for you. Simple questions such as your body temperature, any symptoms such as cough or breathing problems, etc. will be asked from you by the consulting staff member. Similar screening questions will be asked from you when you arrive at the office for your treatment.

Arrival at your dental office

You will then be confirmed by the office staff on the scheduled day informing you about your time slot. You may be asked to wait in your car once you reach the office location. You should walk into the dental office only when you get a confirmation SMS or a call from the office staff. The day at the office is scheduled and pre-planned in such a way that there is minimum inconvenience to the patients arriving at the dental office. 

Carry along accessories

The office staff will let you know if you need to carry your own mask or any other PPE. In all likelihood, they will give you a new disposable mask to wear while you undergo your treatment. Please take the advice of the office staff if you need to have gloves or goggles supplied to you as well during the treatment.

Changes in the dental office set up

You may notice no seating arrangement in the waiting area of the dental office as only one patient is allowed to come inside at a given time. Once the patient goes out after the treatment only then the next scheduled patient is allowed to come inside the office for attend the treatment. All high touch items such as magazines or toys have been removed to neutralize any chance of cross-contamination.

Come along caregiver

Patients are advised to come alone for the appointment unless the company of a caregiver is required. Only one patient at a time is allowed inside to avoid crowding and to maintain social distancing at the office. With a child, it is being advised that only one parent should accompany the child to the dental office.

During Care

You will find everyone in the dental office including your dentist and other staff wearing PPE and gloves.  Every surface that gets touched by anyone is getting cleaned every time before a new patient comes in. Separate emergency rooms have been made for patients who may need to stay longer at the office depending on the nature of their treatment.

Under the new protocol and guidelines, patients’ next visit to their dentists in Texas will be a lot different than earlier one. This new protocol will help you in protection against coronavirus while you continue to receive dental care. Our staff is going to make you feel at ease. In case of any further queries or clarifications, feel free to call us or drop an email. You may also visit our website for a live chat. We want you to KEEP SMILING & Be SAFE.

There are various reasons for carriers to deny an insurance claim. The reasons for denials can vary depending on the payer, however, the first thing to consider is to know why the claim was denied? The good news is that appealing a denied claim is much easier.

Preparing to Appeal a Denied Claim
Once you are confirmed about the reasons for denials, there are some simple steps you can take to appeal a claim denial.

• You need to make sure that all the information entered is accurate and clear.
• Make sure you have all the required information related to procedure, diagnosis and treatment plan
• Have an understanding of the appeal process for specific insurance or payer you are submitting the appeal to.
• Verifying the guidelines according to the payer’s policy

Reasons for Claim Denial
One of the well-known reasons for claim denial is submission of an inaccurate information. Therefore, attention to detail is of utmost importance for billing and coding. Submitting the right claim for wrong treatment is quite common and this happens because the practice is already occupied. So, there are more chances of mistakes. A thorough and detailed system of checks will go a long way in resolving errors.

Your dental practice can avoid denials by asking these simple questions:

• Are the identification numbers, group numbers, policy numbers, and any other identifiers correct and complete? 
• Is the physician’s provider identification number correct? 

Another common mistake is incorrect coding or treatment diagnosis. It is important to use the most up to date codes. Another way to avoid mistakes is avoiding the confirmation of benefits. The patient’s insurance benefits should be verified before the visit is scheduled.

At Capline, our experts can help you appeal a denied claim. We work relentlessly to solve these problems. Get in touch with our experts and say goodbye to claim denials and rejections.