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Common Dental Insurance Pitfalls — Part 2

Post-Appointment Dental Insurance Claim Management Checklist

The patient’s dental appointment wraps up, they’ve received a comprehensive detailed treatment plan with all insurance implications identified, and the patient has made a confident and informed decision to proceed with the recommended dental work. It’s all smooth sailing from there, right? Not quite — the dental insurance and dental claim management processes have only just begun with the completion of the treatment plan.

Last week, I detailed common dental insurance pitfalls that can occur during pre-appointment front and back office activities, including not investigating deeper with the insurance company beyond the preliminary report to develop a comprehensive, fully detailed treatment plan, not giving the front office staff enough time to develop the plan for the patient, and not differentiating multiple plans under a single dental insurance carrier.

To ensure compliance and coverage with the dental insurance carriers post-appointment, it is critical to have a tight methodical management process in ensuring every little detail is covered for the dental claim to be approved.

Post-Appointment Insurance Claim Checklist

  • Provide thorough, detailed evidence of clinical documentation of the work that needs to be performed (i.e. x-ray v. intraoral photo documentation, detailed notes, and description of the problem, etc.)
  • Send the correct x-ray needed to document the problem. Explain to the insurance carrier exactly why the work needs to be done. The more you spell it out, the easier it will be for the insurance carrier to understand the problem and approve the claim. Details to include are the tenure of the dental problem, history, and type of recommended treatment (replacing a crown v. repairing the old one).
  • Double-check to make sure the claim actually made it to the insurance company. If the payer ID or ID numbers are incorrect on the claim, the claim won’t make it to the insurance company. Call the insurance company and clarify what ID numbers are needed (payer ID from the insurance card or social security number) to ensure claim delivery.
  • Provide a list of insurance payer ID numbers at the front desk for easy cataloging and submitting of claims.
  • Check the ‘rejections’ file in in your dental claims software. Claims that need additional proof can be rejected and be filed away automatically, which can be missed if not regularly checked and cause a delay in payment.
  • Differentiate between the (1) rendering provider and (2) billing provider.
  • Pay close attention to the input of patient information (payer ID, ID numbers, etc.) into the insurance software management system. Providing adequate software training upfront will help mitigate mistakes and increase the likelihood of claim approvals and ultimately getting paid.

Most Common Treatment Denials: Periodontal & Cosmetic Work

Common treatments that see the most dental insurance claim denials are periodontal and front teeth work. It’s difficult to prove the patient actually has the disease, but differentiating between the prevention and active treatment of the gum disease is imperative for payment approval. Provide a strong narrative that describes the presence of the disease and provide additional pictures beyond the x-ray, like intraoral cameras.

Insurance carriers often categorize anterior restorations as cosmetic, which isn’t covered by most insurance plans. The best approach is to always tell the patient that front teeth work could be denied and provide the full price before they start the treatment. Having the conversation upfront will allow for no financial surprises after the work is complete.

Dental claim management is an important priority in day-to-day operations of a dental practice. Having a dedicated expert to manage this process is an efficient option to maximize collections and overall workflow among the back and front dental office staff. A claim expert understands the different nuances of each insurance carrier and can detect patterns for more efficient and collected payments.

What common post-appointment insurance pitfalls beyond this list has your dental office experienced recently?

2 thoughts on “Common Dental Insurance Pitfalls — Part 2

  1. Is there any way to make two corporations under which the same dentist could do fee for service in one location and not in another, particularly if the locations are 30 miles apart? It seems to me that if that is not possible it might be a right to work type of legal thing that should be challenged. Why shouldn’t a person be able to contract one way in one location and not in another. Regardless, is it possible? If so, it could make for some wonderful practice associations as some treatments are just not very feasible under PPO plans but could be referred to another practice so that it could be affordable (all on four , very complex cases, complex TMD/night guards, splinting of lower anteriors, etc) in which PPO fees just don’t cover the costs involved to do them well so they often are not done or not done well. The button below says, “post comment” so in the instance that this is posted openly on line I will leave a pseudonym for my name.

    1. You CAN be in network in one location and out of network in another. When you add a second location you need to notify the insurance company that you will be out of network at that tax ID and location. There will be some re-processing and claim resubmission that occurs at first but it is possible. Most claims are associated by Tax ID so separate tax ID numbers are helpful in this instance.
      I hope this answers your question.

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