Managing Insurance Claims Effectively

Important Guidelines to Help Guide and Improve the Process

DENTAL INSURANCE CLAIMS may be denied, delayed, or alternate benefited for a myriad of reasons, all of which create extra work for the office staff and collections delays. DCA helps position our supported practices to reduce unnecessary claim denials.

To improve collections and reduce your accounts receivable, follow these important guidelines:

Days 1-2

Submit insurance claims ensuring all the details are complete and accurate: x-rays (pre & post-op), narratives, charts, etc.

Insurance denials due to incorrect claim information comprise most of all denials. Per the American Dental Association (ADA), a clear and concise narrative should include:

• The clinical condition of the oral cavity

• A description of the procedure performed

David Neal Vice President, Revenue Cycle

Ally Since 2018

• The specific reasons why extra time or material was needed

• How new technology enabled the procedure to be delivered

• Any specific information required under a participating provider agreement

Days 21-30 (from date of service):

During the claim status call, within 30 days of the date of service, if the insurance company said it did not receive the claim, confirm the information within the system is correct, for example:

• Eligibility of subscriber

• Full name

• Date of birth

• Subscriber ID number

• Relationship to the subscriber

Upon verification resubmit ASAP (electronically, by fax, or by secure email) and confirm receipt immediately. If a claim is denied, find out why and see what further documentation is needed. Make note of all communications in the practice management system (PMS).

Day 30-60 (from date of service): Time for another look back.

Check for any unpaid claims from the past 30 days and make sure the 21– to 30-day claims have been processed. If anything is outstanding, follow up with the insurance company again to check the status of payment and see if it needs additional information. Utilize the patient to assist with the claims processing when necessary.

Many dental plans have clauses in them stating that only procedures that are medically or dentally necessary will be covered. If the claim is denied, it does not mean that the services were not necessary. The problem is that the insurance company’s consultants make that determination based on the submittal of the dental claim form, radiographs, and/or other submitted documentation. This method of benefit determination does not take into consideration the clinical judgment of the treating dentist. Treatment decisions should be made by the patient in consultation with the treating dentist.

Per the ADA, it is recommended that you appeal the benefit, and it is a good idea to include any information that you may not have sent with the original submission. A proper appeal involves sending the carrier a written request to reconsider the claim. Additional documentation should be included to give the carrier a clearer picture of why you recommended the treatment. Also, you may want to ask to have the dental consultant contact you directly if the claim is going to be denied again and it may help to leave a date and time that you will be available for such a consultation.

The dental office will be in the best position to provide the best care for patients when it is financially stable, so establish a scheduled time each week to work AR and collect insurance payments as quickly as possible. DCA can help ensure that your staff understands the steps to file claims and follow up on payment status.

Plus, for our Denticon clients, we have developed best-inclass tools to help work AR and follow up on open claims efficiently.

It is widely understood that many patients do not understand how their dental benefits work. They do not understand that dentists who attempt to deliver ideal care may find that the constraints of a given insurance policy do not align with the treatment plan. Getting the proper documents completed by the patient (financial policy/FA, treatment plan, etc.) will help the office collect on denials that may ultimately be the patient’s responsibility.