In the modern era, everyone relies on insurance to cover their dental charges. The dental practice is not only about providing service and receiving payment for the same. In most cases, it is the dental professional’s responsibility to manage the dental claims process. End-to-end dental claims processing involves several policies which one needs to adhere to in order to ensure an efficient revenue cycle. This article focuses on enlightening dental professionals about such dental claim processing policies.
1. Insurance Contract: Patients mostly prefer visiting in-network dentists & dental specialists. Being an in network dental professional widens the range of potential patients. To fulfill this criterion, a dental professional has to sign a contract with the insurance company. This contract is legally binding, and dental professionals are required to adhere to the requirement of insurance contracts. Furthermore, by signing these insurance contracts dental professionals accept the predetermined charges as full payment for the provided services. Apart from facilitating providers benefits, these insurance contracts also provide dental practice coverage such as medical malpractice, employee benefits (health, disability, life), provider benefits, property and casualty benefits among others
To protect dental professionals from making any regrettable mistakes, American Dental Association (ADA) offers contract analysis programs in conjunction with the regional dental association. This reviewing process takes approximately four to five weeks, and the findings are forwarded to the dental professionals.
Below are some points that a dental professional should confirm before signing an insurance contract:
2. Patient Eligibility: Each patient has their own service eligibility criteria based on the type of their insurance policy. A dental professional is required to know the number of appointments required for the treatment, if the patient is eligible to get the service on till the last date of treatment, if the spouse, children, and other dependents are covered under the insurance policy, and their age limit with respect to the dependent’s dental coverage. If there is any uncertainty, the dental professional should confirm the same with the insurance company. Furthermore, the dental professional should have an idea about the treatment estimate and out-of-pocket cost to enlighten their patients prior to the treatment. Failure in ensuring any of the above details can lead to future inconvenience and even claim denials which in turn impact the revenue cycle.
3. Pre-Authorization: Few dental treatments such as pediatric dental orthodontic benefits require pre authorization by the insurance company. Dental professionals are required to be well-versed with the treatments that require pre-authorization. Failure of getting the authorization before the services are rendered can lead to claim denials.
4. Claim Submission: Claim submission is the most crucial step in revenue cycle management and involves several intricacies. For instance, if the patient’s dental services are covered by more than one insurance company, the dental claim has to be submitted in both of them. When a dental professional signs a providers insurance contract, the payer provides claim submission guidelines. These guidelines will include a list of required documentation, dental codes, required treatment details, etc.
While submitting dental claims, avoid some common mistakes listed below to avoid claim denials:
5. Claim Inquiry, Appeal & Resolution:
Once the claim is submitted by the dental professionals, dental professionals receive EOB (Explanation of Benefits), that includes several details such as patient’s coverage, payment sanctioned, and reasons for deducted payments and claim denials, etc. If a dental professional is still uncertain for the reason of payment deductions and claim denials, they are eligible to inquire about the same by filing a request to the insurance company. The inquiry can be done on call as well via e-mail to the appropriate executive of the company.
In case of claim denials, a dental professional can appeal the rejection within 180 days, along with supporting documents and other required changes inferred from EOB and claim inquiry. If the claim is denied the second time, a dental professional can request a peer review. (A peer review involves a group of dental professionals that agree to review the denied claim and the appeal). However, the decisions made by peer reviews are not legally binding, and insurance companies are not liable to pay based on their decision.
If the insurance company finds the claim appeal valid, dental professionals get a written notice, along with the payment.