Appealing a dental insurance claim denial is necessary because nearly half of the practice's revenue depends on it, and payers make it difficult for providers to avoid reimbursing the claim. If the practice believes claim adjudication is inappropriate, appealing is a reasonable resolution with the insurer.
Insurance companies focus on profits by collecting monthly premiums while systematically denying claims. There is always some language in the contracts through exclusions, frequency provisions, or limitations to challenge payment by reducing payouts, leading to higher profit margins. That means using all precise information, supporting documentation, and unwavering confidence in the claim process. Even for seasoned billers, this is daunting and intensive work.
Capline Dental Services provides billing experts to save your team members time from lengthy calls with insurers and focus on patient care. Here are successful tips to tackle dental insurance claim denial and help patients receive the benefits they are entitled to.
Before submitting an appeal, review the EOB (Explanation of Benefits) to identify the reason and avoid confusion. Sometimes the words written are tricky. For instance, the language in the EOB says the procedure is inclusive of another, which means insufficient documentation.
Practice should be aware of the jargon when working with insurance. If the reason for the claim denial is indefinite, do not hesitate to contact the insurer for clarification. It maximizes the chances of a successful appeal before formulating the response. Understanding the reason is the key to addressing the issue and avoiding patterns.
Denied dental insurance claims do not require a new claim. Instead, an appeal for reconsideration to the insurer with the following labels:
The time to respond is 30 days, and if the insurer does not revert, follow up with the appeal department to confirm if they have received the appeal and how long it will take to process. What do you do if the insurer denies the claim a second time? The final opportunity to appeal involves the patient as a benefit of having a dentist-to-dentist discussion between the provider and the dental consultant for better results.
There are two options for claim denial. Close the claim and bill the patient, or leave the claim open and appeal it. Choosing the second option is better for the patient and the practice. Close the claim, and recreation prevents the dental software from tracking the original claim submission date. It affects its aging category on the insurance aging report, meaning a delay in payment for the insurer. Recreating can result in the claim getting lost. If the claim is closed, recreate it. So that it does not affect the collection percentage and the dental practice brings the revenue it deserves.
There are dental plans that outsource claims reviews to consulting firms, and here are the following reviews:
The full potential of insurance coverage is through understanding the terms and conditions, and later educating patients about the benefits and limitations to avoid surprises.
The steps include the following:
Although appealing rejected or denied claims can be challenging and time-consuming, they can become a powerful opportunity with a robust strategy, such as minimizing manual efforts and automating follow-ups, to safeguard and enhance revenue streams.
Let the RCM experts at Capline manage the insurance claim submissions and appeals so that the dental practice's staff can focus on the patient and run the office.
The professionals handle the claim with precision the first time. The experts have specific strategies for each insurance company to handle insurance claim appeals quickly.