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Cross Your T’s And Dot Your I’s To Avoid Dental Claims Being Denied

Articles, Practice Life

Have you ever heard of Warren Buffett, the man who amassed most of his fortune through heavy investments in the insurance industry? Of course, you have—his net worth is rumored to be somewhere in the upward realms of one hundred billion. Understanding the business model of insurance companies, Mr. Buffett took a gamble and emerged as one of the richest men in history today. You see, insurance companies are in the business of making money, not spending it.

One of the most common ways insurance companies ensure their profits soar is by collecting monthly premiums from their members (our patients) and then denying as many claims as possible by referring to the literature in the patient’s contract, specifically the exclusions, limitations, and/or frequency provisions. Exercising their right to deny payment of a claim based on this literature will ultimately result in decreased payouts and increased profits.

Now that you have a better understanding of an insurance company’s business model, you need to think like an insurance company and be sure to dot your I’s and cross your T’s before you send out that dental claim for processing. Here are the three most common ways insurance companies can deny dental claims and some ways you can avoid them.

1. Lack of information from the provider.

At least 50% of dental claims for basic and major services will be placed on pending status and sent back to the dental office, requiring you to send additional information for the claim to be considered for payment. Most of the time, the claim is sent back due to a lack of information. Be sure to send a recent full mouth series or periodontal charting from within the last six months for claims requiring this information, such as periodontal, endodontic, orthodontic, and other basic and major services. In some cases, the insurance company will delay payment by requesting a detailed narrative with a written explanation of necessity. Always make sure to be swift and timely with any requests from the dental insurance company to facilitate claim processing.

2. Untimely filing.

Dental claims should be submitted upon completion of the services provided. Failing to submit the claim on time is a quick scapegoat for the insurance company to deny the dental claim. Most PPO plans require the claim to be submitted within one year from the date of service. There are also some Local Union plans that have even shorter timely filing periods, such as ninety days. If the claim remains unpaid past these deadlines, you will then be at the mercy of the untimely filing rule and can expect to have that claim denied and unpaid, should you resubmit. You may be able to request an appeal, but most times this request will be rejected.

3. Limitations, exclusions, and frequencies.

Dental plans are not created equal. Most dental plans are based on what the patient’s employer has agreed upon with the dental plan provider. Limitations, such as annual or lifetime maximums, ensure to control how much is paid out on a dental plan policy. Frequencies help to keep the insurance companies’ costs down by ensuring a patient can only be covered for certain procedures a few times a year or every few years. Excluding or downcoding certain procedures occurs all too often and helps minimize insurance payouts. Don’t expect reimbursement for a dental implant when the patient could’ve had a three-unit bridge instead. Most of the time, they will downcode the more expensive procedure to a less costly procedure and provide an alternate benefit resulting in lower reimbursement. The list of reasons for non-covered procedures, due to limitations, exclusions, and frequencies, can go on and on as they usually vary from plan to plan. This is why it is vital to find out what is covered and not covered before performing any procedures by obtaining a breakdown of benefits and, if necessary, submitting a predetermination for more costly procedures.

You see, insurance companies are in the business of making sure their quarterly earnings are soaring. They tend to make decisions based on their own pockets and not based on what’s best for your patients’ health and well-being. That’s why you should make sure everything is in order before submitting a claim.


About the Author:

Kyle L. Summerford is president of Summerford Solutions Inc. Being a dental office manager, dental practice consultant, and dental coding educator, his company provides services to dental practices and their staffs nationwide. Kyle has lectured at many CE events and academic institutions—Stony Brook University, New York City County Dental Society, and Georgia Regents University. He’s authored many Dental Coding with Kylearticles. He’s the founder of Dental Office Managers Facebook Community and Dental Manager Connect. Contact him at kyle@dentalmanagerconnect.com.

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