Preventing And Managing Dental Insurance Claim Denials

The rejection of an insurance claim is a common challenge faced by a dental practice. Claim denials have a bearing on the financial bottom line and cash flow as well as the level of satisfaction and trust among patients. Understanding the dynamics of dental insurance claim denials is the initial step in efficiently addressing them.

Understanding the claims process

Get the exact billing requirements of any plan for every patient. These can be obtained from the patient or the website. Follow the plan's instructions if the practice is informed of a denial in a claim, further investigation would be necessary. The scope of claim rejection also needs to be understood from multiple perspectives:

• Dental insurance varies from conventional general health insurance concerning coverage limits, the different procedures that can get covered as well as the frequency of rejected claims.
• When insurance claims get denied, it leads to a considerable loss of revenue and time.
• Based on the procedure and coverage, claims that are denied can negatively affect relationships with patients.

Tips to avoid claim denials

Automation can play a critical role as it helps to eliminate human errors that can lead to denial in the first place. There are software packages that can self-code precisely and this helps to significantly raise the chances of reimbursement. Claims that are accurately processed at the first instance help in boosting the revenue pipeline.

The practice must check the plan of every patient at every visit. Common reasons for claims getting rejected are incorrect data or errors in the pre-authorization report. One can check the patient portal for updated information as even a single error can cause a denial. The staff must also be trained in improving the quality of patient data.

Previous rejections are a source of learning. This can aid in reducing the rejection rate. One can also analyze rejections and understand how the problems occurred and thereby be avoided in the future.

Deadlines are a vital element in claim submission. A practice must adhere to deadlines that are stipulated by the insurance company.

Outsourcing the task of billing, collection, and insurance to experts can considerably the possibility of denials and a higher level of customer satisfaction.

Managing denied insurance claims

There are several ways and means of handling denied claims. A dental practice must explore the most suitable option for resubmission or an appeal to get claims passed.

• The denial must be carefully read and understood. The reasons for claim denials could be several. The examiner would mostly choose from a list of denial reasons that matched the situation but that might not be sufficient to warrant a denial.
• The practice needs to follow the steps and instructions of the specific plan to appeal any denied claim.
• Ideally, the practice must not use a self-created template unless it is in sync with the plan’s directives.
• A request must be sent in writing to reevaluate the claim in addition to a follow-up through a phone call.
• Additional documents can be provided to the insurance company that would enable the examiner to attain a better understanding of why a specific treatment or procedure was followed and recommended. This will help in getting the examiner to agree on the treatment rendered and approve the suitable benefits accrued by the patient.
• The dental team needs to despatch the resubmitted claim to the specified department of the insurance company as mentioned in the plan or policy statement. One should also use the ‘appeal’ in the cover letter that is sent along with the appeal document.
• Documents that can facilitate getting claims passed can include radiographs, photographs, and dentist notes. The practice can also provide a description that offers additional useful data.
• The practice needs to establish the necessity of a particular treatment or procedure from a dental perspective. Not providing adequate medical necessity is a common observation and this can offer considerable leverage to get claims passed.