Why aren't you getting paid? As dentists, you might assume claims should get paid easily. After all, you rendered the necessary treatment. Unfortunately, it's not that straightforward. Let's go over some of the strategies my team at Arizona Dental Billing uses to address denials and underpayments.
Review the EOB carefully, and pay close attention to codes, coverage limits, and other details.
Beth Wallewein.
Always use the Code on Dental Procedures and Nomenclature (CDT) book if you are unsure of the correct coding. Each year, the ADA updates the codes, so you want to make sure you are familiar with the newest codes. With hundreds of codes, it's important to check that you are using the correct one. Familiarize yourself with the codes!
Billing advice: I like to use the term "clean claims." Sending a clean claim is one that is accurate, complete, and error-free. A few areas to verify that a claim is "clean": ADA coding in conjunction with teeth numbers and/or area of the oral cavity; the patient's name and date of birth; the rendering provider, the billing provider national provider identifier, and tax identification number data; prior prosthesis or scaling and root planing dates; and orthodontic information. It is imperative that the ADA claim form is filled out completely and correctly to avoid rejections.
Let's talk about coverage. Was it denied as a noncovered benefit? Or was the procedure denied due to a frequency limitation? If so, these typically cannot be reprocessed. Maybe it was denied as all-inclusive of another procedure on the claim. Always check the policy benefits to ensure the claim in fact denied a procedure correctly. Insurance companies make mistakes (especially now that artificial intelligence is processing claims)!
Billing advice: Whether your front-office team handles insurance verification or you outsource this service, it is imperative that coverages and frequency limitations are checked. Prior to a patient's visit, the patient should be aware of the services that will not be covered. You are then able to collect from the patient at the time or service and are prepared for that insurance denial.
Identifying any errors in the explanation of benefits (EOB) can help you pinpoint whether the claim was incorrectly processed or if additional documentation is needed.
Billing advice: Do not close a claim out and accept it for what it is if you feel unsure. Always call the insurance and ask questions. Many times, they admit the error and reprocess the claim right then. Try it!
Appeal the denial with the correct documentation.
If you believe the claim was denied in error, submit a formal appeal. I do not suggest resubmitting a new claim form, this can lead to a duplicate claim and another denial. An appeal involves sending an official appeal letter on office letterhead that includes additional supporting documentation, such as x-rays, intraoral photos, and clinical notes. Make sure to follow the insurance company's appeal procedure and meet their deadlines. A well-documented appeal increases the chances of getting the claim reconsidered and paid correctly.
Billing advice: Spell it out for the insurance company. Break down those clinical notes, point out decay on the x-rays, and circle the fractures on the photos. Whatever you need to do to prove medical necessity, do it! I also recommend asking for the reviewing dentist's name and license number for your records.
Request an adjustment.
When the claim was underpaid or pending, ask for the claim to be reprocessed with additional information. Many times, this can be done over the phone or in the insurance website portal. Maybe they are looking for coordination of benefits (COB) details or they may need specifics about a procedure. Many times, codes are deemed nonbillable or all-inclusive. Provide additional information and try to get that overturned.
Billing advice: When calling in a COB, have all primary and secondary dental insurance information ready. This includes the subscriber name and date of birth, the effective date of each policy, and the type of policies (employer, retiree, or individual). Super easy!
Insurance billing is tedious and time-consuming, as insurance companies make it difficult to just get paid. Focus on these strategies and you'll improve your overall financial outcomes.
With nearly 20 years in the dental industry, Beth Wallewein specializes in front-office operations. She founded Arizona Dental Billing, where she has helped dental practices nationwide. Wallewein can be reached at [email protected].
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.
