Why would insurance deny claims?

Why would insurance deny claims?

What is the dental claim process?
December 27, 2021
What happens when a dental claim is denied?
January 3, 2022

Insurance claim denial not only affects the cash flow but also damages your relationship with your  patient. You can appeal the claim denied, but even if they leave the claim status as pending, that is  something your patient and practice wants to avoid. 

Insurance is a business, and by understanding the reasons for claim denials, you can relatively fix  and address them. The insurance company offers software tools to help you prevent claim denials  due to clerical or reimbursement errors. For elective care, utilize the tool with awareness to avoid  any denied claims. 

Pre-authorization process 
Pre-authorization needed but not obtained can cause you and your patients unnecessary money that  eventually decreases patient satisfaction. Understanding the insurer’s requirements is essential, and  you will know what to do. The insurers always opt for the less expensive option, so it is better to get  proactive pre-authorization for a procedure rather than retroactive. 

Claim form issues 
Insurance companies look for details and continue to refuse or delay the claim. The clerical errors  such as the patient’s data, ID number transposed, outdated information are quick to fix, but they  prolong the RCM. Incorrect procedure codes and diagnosis is often a reason for claim rejections.  You can successfully appeal, but again prevention is better and saves time. 

Well-trained coders or billing software can help you with the correct codes and cannot be  substituted. 

Claim filing after the deadline 
Every insurer has a deadline for submitting the claim. If you miss the deadline, they have different  policies for secure reimbursement. Some situations call for detailed paperwork, while others with a  phone call. Billing software can be a trigger to notify once you miss a deadline for a provider. This  

way, you can submit claims as soon as possible after the rendered service, so your revenue cycle  doesn’t slow and can increase patient satisfaction. 

Medical Necessity 
The insurance provider won’t pay for the services they believe to be medically unnecessary. These  are difficult situations for everyone where medical necessity is not understandable, then effective  communication with patients, insurers, and billing staff can help make informed decisions. 

Claim denials due to insufficient medical necessity can result in either your practice absorbing the  cost of the rendered service or the patient making the entire payment. Both the options are not  feasible for the RCM. 

Seeing Out-of-Network Provider 
Insurance companies keep changing the provider from year to year, and mostly the patients are not  aware of the changes. Use of Out-of-Network is not an option to receive full benefits. 

Obtaining patient insurer information during the appointment can allow your billing staff to  determine whether your patient plan is a part of your network and, if not, then what benefits they  can expect. Your practice can use billing software to see the changes in the network. 

Coordination of benefits issues 
Delays in reimbursement due to issues in coordination of benefits such as inaccurate COB  information, failure to attach EOB, and incomplete details can leave the status in the air. The patient  has more than one plan and can use it to cover the expenses. To process the claim, the provider  needs to collect the primary and secondary payer at each visit.

Here is the state wise list of Dental Insurance Companies