The top 7 reasons dental insurance claims are rejected

One of the most common areas of concern for dental practices is creating and managing sustainable cash flow. After dental practices were forced to shut down due to COVID-19, many struggled to find ways to bring in revenue. Now, as some restrictions have lifted, practices are experiencing varying levels of cash flow-related challenges. Some are seeing an influx of patients and, as they try to squeeze all services into the schedule to maximize revenue potential, they can't keep up with claim submissions and resubmissions. On the other hand, some practices are seeing fewer patients due to ongoing concerns with COVID-19, and every reimbursement is critical to keeping the doors open.

Steve Roberts.

Regardless of your current situation, incoming revenue is important. You're well aware of the process from service to payment. You treat a patient, submit the claim to the insurance company, and wait for the reimbursement. However, it's common for there to be another step in the process: submitting more information to the insurance company so the claim can be approved. This means not only more time and effort for your back office staff but also delays in payment.

It is important to submit complete and correct claims now more than ever. Here are seven common reasons why your claims might be getting rejected and some steps you can take to expedite approval and payment.

1. Failure to update codes

Every year, the ADA releases its updated Code on Dental Procedures and Nomenclature (CDT Code). Practices that forget to update their codes in the new year will undoubtedly experience an uptick in the number of claims that are rejected. There are many resources available on the web to guide your practice on which codes are being added, removed, or updated.

2. ADA code validation mishaps

This can be as simple as using an invalid procedure code. It could also be that you have the correct code, but the insurance company requires a different code to process the claim. Make sure your practice is staying current with annual code revisions.

3. Missing or invalid subscriber ID

A missing or invalid subscriber ID refers to the insurance policyholder's subscriber ID number. If you are having issues with the subscriber ID, try inserting the policyholder's social security number (SSN) in the subscriber ID field and type the subscriber ID in the SSN field. If this doesn't solve the problem, you will want to contact the person's insurance company.

4. Subscriber not found

This issue indicates that the subscriber is not on file or that the submitted ID doesn't match the insurance company's records. If you find that you're receiving this error even though you have verified the subscriber ID, make sure the information is matched with the correct insurance company.

5. Missing or invalid patient information

Missing or invalid patient information can cover any type of patient information. If the patient is not on hand to verify his or her details, you should be able to obtain the information by reaching out to the insurance company or by checking his or her explanation of benefits.

6. Incorrect entity address

An issue around entity address can include the address for the patient or the subscriber. Always confirm that the address your patient provides matches what his or her insurance company has on file. The error could be as simple as your patient moving and forgetting to update his or her records. If you think you have the correct information but are still having issues, you can verify the address on USPS.com to confirm the ZIP code and the formatting.

7. Duplicate claims

Sometimes a claim can accidentally be submitted more than once if your practice uses more than one way to submit claims, such as by mail, an electronic claims processing solution, or a practice management system. If your claim is rejected because it is a duplicate, this typically means that the insurance company accepted the original claim. Duplicate claims may lead to interrupted payment for the claim. It is best that your practice sticks to a single method for submitting claims, ideally using an electronic claims processing solution for increased transparency on why the claim was rejected and how to solve the issue.

The solution

In addition to keeping up with code updates and being more diligent about the accuracy of claim information, you may want to consider an electronic claims submission solution that can validate claims before they are transmitted. The ideal claims processing solution will proactively analyze and prevent claim rejections for many, if not all, of the reasons outlined above.

Having insight into the most common reasons why claims are rejected and how to resolve the issues will help your practice reduce the total time spent on claim submission and get paid faster.

Steve Roberts serves as the president of Vyne Dental.

The comments and observations expressed herein do not necessarily reflect the opinions of DrBicuspid.com, nor should they be construed as an endorsement or admonishment of any particular idea, vendor, or organization.