February 21, 2019 admin

How to Reduce Dental Claim Denials?


Dental billing is a complex process, and errors in it lead to thousands of dollars in lost revenue. Dental billing services are available to empower practices that want to stay ahead of the game. Besides, it is crucial that providers know the top reasons for dental claim denials as well as delay.

The man who made major of his fortune by massively investing in the insurance industry. His net worth is said to be around $100 billion. Learning the business model of insurance companies, Mr Buffet took a risk and came out as one of the richest men in history.

Now you know, insurance companies are in the business of making money, not vice-versa!

To ensure that their profits rise, insurance companies collect monthly premiums from their members (a.k.a patients). Then avoid as many claims as possible with reference to the documentation in a patient’s contract.

Especially the exclusions, limitations, or frequency provisions lead to the claim denials. Insurance Companies exercising their right to deny payment of dental claims based on these documents eventually result in reduced payouts and increased profits for the company.

As per a recent research,163 million Americans are covered by a dental benefit plan. A recent ADA survey indicated that almost 65% of patients depend on their insurance for some part of their dental treatment expense.

Even dentists who do not file dental claims directly for their patients are aware that the patients with insurance rely on it to aid them to pay for the treatment.


How to Reduce Your Dental Claim denials?

  • Reduce submitting incomplete information and documentation
  • Avoid late claim submission
  • Do not miss on any X-rays and claims
  • Include a description of the X-ray by the service provider
  • Be aware of the exclusions, frequencies and limitations
  • Form an office policy for a smooth process

We have listed the most common ways of dental claim denials by insurance companies explained in brief.

Incomplete information and documentation

The lack of documentation has led at least 50% of dental claims to return to the office or on pending status.

Insufficient information is one of the most common reasons for claim denials.

The detailed and correct information about the patient and teeth including other details such as their ID number, service date, the claim form should be submitted.

Along with it, information such as the provider’s name, license number, address, and a tax identification number that is TIN, EIN or SSN of the treating dentist are as well essential.

Various plans require specific documentation for processing.
For example, in a case of scaling and root planning, plans typically require prior charting and X-rays showing bone loss.

As per a recent study, a periodontal charting or full-mouth series from the last six months for endodontic, periodontal, and orthodontic procedures and other essential and primary services is required by some plans.

Providing more information about what were the steps taken regarding treatment when mentioning it in a dental claim to avoid claim denial is generally advised.

Well Grounded dental billing companies usually call up the plan and request information about what documentation is required for the procedure.

Late claim submission

Missing a deadline creates a situation where you could lose your money forever. Above all, train your team and reinforce that no claim should ever be late.

Having a reminder in your front office will aid your staff to avoid this common mistake. Reminders for individual payers can be posted or distributed in a document throughout the practice.

In case of a third-party medical billing company, they can serve as your partner and be in charge of these deadlines to submit claims well ahead of the required deadline.

No matter what, claims should be filed immediately after the dental services are availed. Insurance companies may deny a claim due to late submission.

The general rule for PPO plans is to file the claim within one year from the date of service.
There might be a shorter time filing period of 90 days for other plans.

Missing X-rays and claims

The third-party claim payment, due to missing X-rays and claims is one of the major concerns as per the American Dental Association(ADA).

Before the acknowledgement of the receipt by the payer dental offices often send dental claims or X-rays several times. Thought the X-rays are presented with the claim, the dentist receives an explanation of benefits (EOB) for the same.

As per the recommendation of ADA each office should contact each carrier individually to meet the claim processing requirements precisely.

The poor standardization of attached documents from carriers and the incompetence to reference attachment requirements for several carriers in a unified location is the main reason for the misunderstanding.

The following advice on sending X-rays is provided by the California Dental Association (CDA).

Include a description explaining what the X-ray shows, which explains the reason for treatment.

A printed format along with a brief explanation that justifies the treatment and the claim can be provided for digital X-rays.

Proper labelling the patient name and date on the X-rays is essential.

Exclusions, frequencies, limitations

Limitations, exclusions and frequencies vary from amongst different insurance plans.

The amount available from the dental policy depends on limitations such as annual or lifetime maximums.

Along with frequencies, patients have a cover only for specific procedures every few years or a few times a year.

For example, Individual insurance plans may cover the replacement of crowns only every five to seven years.

One of the most common frequency limitations is for examinations, prosthetics, and periodontics. Such as limitations on how often periodontal scaling, root planning and other periodontal surgical services can be performed on the same arch or teeth within the arch.

Age is another limitation. Many employer group contracts have limitations on specific procedures based on patients age.

Such exclusions aid to decrease payouts in favour of the company. It is crucial to get a copy of the patient’s certification of insurance that mentions the limitations, exclusions and scope of benefits of their plan before performing any procedure.

To reduce the frequency of insurance issues many offices might also develop a policy for how dental claims will be handled. These policies are helpful to further explain and present it to patients in a written format during a treatment conference.

The policy can mention office responsibilities and patient responsibilities in regards to insurance.

For example:

1. Office Responsibilities
  • Complete insurance claims and submits them within 24 hours of treatment.
  • Be precise and ensure relevant ADA codes for correct reporting of procedures.
  • If required, submit your insurance again within a specified period.
2. Patient Responsibilities
  • Pay the fees not included in the dental plan right away.
  • Provide the office with detailed information regarding insurance coverage to ensure accurate filing of claims.
  • To pay the balance in full if not paid by insurance after specific billing attempts.

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