One of the most common questions we hear from dental practice owners looking to expand their billing capabilities is, “What procedures can I bill to medical insurance?” However, the key to success in medical insurance billing isn’t necessarily about which procedures you bill; it’s about demonstrating why they are medically necessary.
Health insurance providers care about whether a treatment addresses a systemic or medical condition that impacts the oral cavity. The way a case is documented plays a crucial role in determining whether a claim will be reimbursed. Here’s how you can ensure your documentation demonstrates medical necessity with help from APEX Reimbursement Solutions and DevDent.
Understanding Medical Necessity
To meet the criteria for medical insurance reimbursement, a procedure must be linked to a patient’s broader medical conditions. This requires a shift in how providers document treatments and focus on the underlying medical issues rather than the dental procedure itself. For example, if someone has periodontal disease that has been worsened by diabetes, treatments to help control the periodontal disease are critical tools for managing the patient’s overall health.
Key Documentation Strategies
To ensure successful claim approval, providers must:
Clearly Link the Treatment to a Medical Condition
Insurance providers want to see how a dental procedure treats or prevents a medical issue. Instead of stating that a patient with uncontrolled diabetes and severe periodontitis needs scaling and root planing for “severe periodontitis,” focus on the connection between uncontrolled diabetes and severe periodontitis and how scaling and root planing can reduce systemic inflammation. By making this connection obvious and explicit, you will increase the chances of the procedure or treatment being covered for your patient.
Use Medical Terminology
Chart notes should include terminology familiar to medical professionals and insurance adjusters, not terminology just used by dentists. For example, rather than writing “pain due to wisdom tooth,” use “pericoronitis resulting in chronic inflammation and infection requiring third molar extraction.” This can take practice for dentists used to solely billing dental insurance companies, but it is worth the effort.
Include Supporting Records
Radiographs, physician notes, sleep studies, pathology reports, and other diagnostic materials can strengthen your case for medical necessity. The more evidence you provide, the stronger your claim.
How to Reduce Claim Denials
At APEX Reimbursement Specialists, we are here to help support dental practices just like yours. We can help you reduce claim denials in a variety of ways, including finding dental billing solutions that meet your needs. If you’re ready to give your business a boost this year, we’re ready to help!