Are You in Denial About Denial?

When it comes to managing a dental practice, claim delays and denials are two of the most common complaints that patients and dentists encounter. While every American is not covered by a dental insurance policy, those that do have insurance depend on insurance to offset all or some of the cost of treatment. Denials don’t just negatively impact your practice, but also your patients.

What Claim Issues Delay Payment?

Claims can be denied for a wide range of reasons. The most significant reason for denial or delay is insufficient information on the claim form. With insurance companies processing over 250 million claims a year, and the majority of them being processed by computers, it’s easy to see why errors and delays occur. The most common reasons for delays in payment, according to the American Dental Association (ADA), include:

  • Using an outdated version of the ADA Claim form
  • Not including the proper dentist information (name, address, TIN, NPI, etc.)
  • Using outdated CDT codes
  • Sending claims forms to the wrong insurance company
  • Leaving off the date of service for the treatment
  • Using the narrative section to include unnecessary or unrelated information
  • Leaving out periodontal charting or radiographs

What Denial Rate Should You Expect?

Well-managed dental practices average a denial rate close to 4%. If your rate is higher than that, you should take a closer look at your dental practice’s processes and not blame things on the insurance providers. If you want an outsider’s perspective, you should hire a compliance specialist, like APEX Reimbursement Specialists. A compliance audit of your practice can detect what problems are causing your claims to be denied. Anything from messy handwriting to incomplete claims could be the culprit.

Avoiding Claim Denial

To avoid claim denial at your dental practice:

  • If payers require you to submit paper forms instead of electronic submissions, take time to print clearly. If a form cannot be read by another staff member at your office, you cannot expect a busy claims processor or computer to take the time to make out what it says.
  • Always code to the highest level of specificity. Any diagnosis needs to be coded to the highest level, which means that you should be filling in the maximum number of digits for the code being utilized. If your four-digit diagnosis code requires five digits to be accepted, it will be denied.
  • Carefully fill in all fields. Identify the fields that are most often accidentally left blank (typically date information) and make all employees that fill out claims aware. Double-check the most commonly missed fields before transmitting the claims.
  • Always group transactions by your insurance payers. Doing so will give your practice insight into what payers are the pickiest and why you are failing to meet standards.

If Your Claim Was Denied

Always appeal a claim denial. Only 35% of providers appeal denied claims, and many claims are approved upon resubmission with correct information. Always inspect every claim that returns to your office as a denial to see what went wrong.

Avoid Claim Denial with Help from APEX

Whether you need a refresher on proper coding procedures or need to overhaul your billing procedures, our experts can help. Contact our team today by calling (410) 710-6005. We look forward to working with you to make your practice a more profitable place.