capline dental services

What Are The Types of Denials In Dental Billing?

Things to Check For Dental Credentialing Process?
Things to Check For Dental Credentialing Process?
June 16, 2023
5 Benefits of Working With A Professional Dental Billing Company
5 Benefits of Working With A Professional Dental Billing Company
June 23, 2023
What Are The Types of Denials In Dental Billing?

Claim Denied Written on Red Key of Metallic Keyboard. Finger pressing key.

Denials create more stress affecting the clinic’s efficiency and cost revenue loss. The refusal of payment from the insurance company is one of the most frustrating things the dental clinic wants to experience. 

In the dental industry, there are two types of denials, that is soft and hard. The hard denials in dental billing cannot be reworked or corrected. It is irreversible and often considered as lost revenue or written-off. On the other hand, the soft denials are temporary and can be collected and reworked if the provider provides additional information or correct the claim.

As per the American Dental Association’s National Insurer Report Card, there are five most  common denials your staff should watch out for: 

Missing Details:
You will trigger a denial even if one required field is left blank. Enter N/A if the required field is irrelevant. As per reports, 42% of write-offs happen simply by missing information like security numbers, incorrect plan codes, addresses error, missing modifiers, etc. 

The service or claim already performed:
Claims get flagged as duplicates by the same provider on the same day for the same service performed for the same beneficiary. A duplicate claim will cause a hit to the consistent revenue. 

Service already adjudicated:
The denial happens when benefits for a specific service get included in the allowance or payment for another service adjudicated before. 

Procedure or service not covered by payer: 

That occurs when the patient’s current benefit plan does not cover a particular procedure or services rendered, and the claim gets denied. It can be easy to avoid by calling the insurer and checking before submitting the claim. 

The filing limit runs out: 

Payers have a strict time frame, and if the claim submission exceeds the required days of service,  they will get denied. It is vital to consider the time to rework rejections before filing. There are two types of reviews a clinic receives for incorrect filing – automated, through the system for improper coding; complex, professionals check if the service is covered, necessary, and reasonable. 

81% of claim denials happen due to incorrect coding that a dental staff can avoid through a thorough vetting, collecting patient data correctly, relying on the right claim monitoring software,  and outsourcing to manage the claims. 

How to reduce dental claim denials? 

Reduce submitting claims with incomplete documentation or information. The lack of  documentation or details results in 50% of insurance claims being pending or sitting in the office. For instance, in case of scaling or root planning, provide periodontal charting and x-rays showing the bone loss. Provide more information about the treatment and correct information about the provider and patient, such as TIN, EIN, SSN, license number, address,  provider’s name and tax identification number, patient service date, etc.

Missing a deadline costs a lot of money, which results in a snowball of claims piling. Filing claims daily aid the staff in avoiding common mistakes. Individual payers have separate deadlines to submit claims. Reminder on the front office can serve the dental clinic well to submit claims before the submission date. 

Exclusions, limitations, and frequencies vary from plan to plan. Annual or lifetime maximums depend on the patient’s dental policy. Similarly, specific procedures are also limited to every few years or a few times a year. For instance, crown replacement gets done every five to seven years. Age is also a limitation that aids decreased payout. Getting a copy of the patient’s certifications of the insurance plan will help dental offices before procedures to further explain to the patients how dental claim gets handled. 

Educate the patients about dental insurance and avoid denials. 

  • A face-to-face conversation about the covered and non-covered services and how the copayment works in the patient’s insurance plan can help them proactively decide. 
  • Simple terminologies to make them understand the dental insurance jargon. 
  • Communicate the practice policy on collecting payments to help patients maximize their insurance benefits and receive maximum reimbursement for rendered service. 
  • Once the dental office learns about the type of denials, it is easy to measure, track and categorize which type of denials the office is struggling with, and the office can stay updated with information about the denial trends.