Research reports suggest that about one in seven claims submitted to insurance companies gets denied. The quantum of rejections exceeds thousands every day, and many of these submissions can be easily prevented or resolved.
For a dental practice, the importance of appeal submission cannot be ignored. A sound process helps in ensuring that revenue cycle management for the practice is not affected due to multiple claim rejections.
An appeal submission is about the processing of a request to the insurance company to reconsider a claim denial decision. The team must realize the importance of appeal submission and its impact on the practice.
One needs to note that the practice and the patient can make an appeal to the insurance company. Denied claims impact cash flow, and hence, appeals are usually made by a dental practice. Many claim denials can be reversed if the dental team sends accurate appeals at the earliest.
A typical dental practice will be in-network with multiple insurance companies to attract a larger pool of patients for treatment. Of course, all insurance companies have their own specific format for appeal submission, and dental teams will need to respond accordingly. Insurance portals and websites are the means for making an appeal submission.
There are multiple reasons for the rejection of claims. If a submission does not demonstrate adequate medical necessity or if prior authorization for a recommended treatment is not obtained, a claim can be denied. The dental team might submit a claim within the stipulated timeline. Due to oversight, the dental team might also file a claim for a service that is not covered by the insurance company. In such cases, the dental team needs to handle a denied claim through a successful appeal.
The general steps for an appeal submission to be drafted by the dental team are as follows:
A lot of dental practices are automating processes to make things faster and more precise. Automation takes a fraction of the time needed for making claim appeals and will capture precise information from the PMS or practice management software.
The software can evaluate situations that require an appeal and take remedial steps. It will have a bank of appeal forms for all insurance companies that the practice deals with. It will also send the right records and supporting documents that need to accompany the appeal submission. More importantly, all submissions will be done at the earliest so that deadlines are not missed.
Revenue is critical for any dental practice, and hence, effectively handling appeal submissions will help in garnering lost revenue due to claim denials.
The appeal submission process helps a practice boost cash flows that impact revenue cycle management for a dental practice. Revenue that could be lost for a practice because of a rejection can be reversed. Hence, the dental team needs to be adept at contesting denied claims and recovering potential dues that could be lost. A vigorous appeals process that optimizes the billing and claims process can help a dental practice in the long run.
The dental team needs to follow a few steps in the appeal submission process so that claim appeals are successful.
The dental team needs to thoroughly analyze the reasons for a claim being rejected. Understanding why the claim was rejected clearly forms the basis of a powerful appeal.
The dental team needs to gather all the requisite documents to support the claim appeal. Clinical notes, billing data, patient records, etc., help to support the appeal.
The team needs to draft a clear and crisp appeal letter for arguing against the denial. All the reasons and narratives need to be covered. The team must cite the relevant regulations and attach necessary documents that justify the appeal.
The team must follow all submission protocols of the insurance company while submitting the appeal.
Once the appeal submission is over, regular checking of claim status is a must. A tracking system can help the team to confirm the status and prevent any unwanted delays.
Insurance companies have their own deadlines for appeal submissions. The dental team needs to ensure that all claim appeals are completed before the stipulated deadline.
All the above steps need to be adhered to for efficiently managing the appeals process and thus ensuring maximum recovery of revenue for the practice.
The dental team may come across multiple issues that lead to claim appeals being denied. The team needs to understand that overcoming these common errors can help submissions get accepted by the insurance company while also optimizing RCM. A few errors that the team must be aware of.
By far, one of the main causes for claim rejections. Errors committed due to wrong codes being used lead to incorrect billing and thus impact cash flows. Staff need to be trained so that such errors can be avoided. Coding issues could include:
A lack of medical necessity for the recommended treatment can lead to a claim submission. The team needs to ensure that all documentation that justifies a procedure is attached. A few scenarios include:
An unjustified diagnostic – a test carried out that is against approved guidelines.
Lack of adequate documentation – absence of enough evidence that warrants the need for a specific procedure.
The team needs to ensure that documents are provided to prevent a claim from being rejected. Documents that are usually needed include:
In addition to the above, there are administrative errors that the dental team needs to avoid. Keeping track of submission deadlines is also necessary. Such errors or lapses can be resolved through periodic training of the dental team.
The dental team needs to identify and address all the reasons for claims being rejected and needs to prepare the appeal submission accordingly. This helps the practice to boost cash flows that can positively impact revenue cycle management by lowering potential revenue losses. Capline Dental is a leading provider of end-to-end services to dental practices of all sizes in the USA and can be reached at info@caplinedentalservices.com
