Tag: claims billing

Dental claims are complex. But understanding the workflow involved can help dental practices identify areas to reduce costs and speed up turnaround time. Dental claims processing includes all processes involved in giving care to patients, right from the moment a patient is registered with a dental practice, up until the explanation of benefits (EOB) and payments are finished. There are two ways of submitting a dental insurance claim; one via paper and the other, electronically. Any inefficiencies in these insurance claim submissions end up being a source of additional cost to dental practices. This article will walk you through the dental insurance claims process and everything else you will need to know about dental claims.

After a patient has visited a dental service provider, claims have to go through multiple steps before the patients receive their final bill. The sequence noted below is what the entire process looks like: 

Billing:

The insurance provider is sent a bill for charges for services rendered. This is not inclusive of any charges paid via co-pay upon check-in.

Adjudication:

A certified claims processor will then review the claim, ensuring accuracy and comparing it against the insurance plan to validate whether the services rendered were covered by the insurance or not.

Reconciliation:

If the services received were covered under the benefits, the insurance company will pay the claim based on the allotted coverages. They may pay the entire claim in full depending on the patient’s plan. Otherwise, the remaining balance will be billed to the patient.

Validation:

These amounts are then validated and applied to deductible and maximum out-of-pocket totals as they apply to an insurance plan. Those are updated immediately.

Explanation of Benefits:
An explanation of benefits details the list of services received by the patient, how much was covered by insurance, how much the patient has to pay, and what remains to be billed. An EOB is sent to the patient post-treatment.

Final Billing:

A final bill will be sent to the patient for payment if there are any additional payments that need to be made from the patient’s side apart from the co-pay that was paid upon check-in.

Payment:

It is the patient’s sole responsibility to compare the EOB and final bill and ensure everything mentioned is accurate and billed correctly. Sometimes these numbers do not measure up because of a mismatched procedure code or other clerical error. Once detected, these mismatches can be fixed and claims can be updated without any penalty.

What are the necessities for filing a dental claim?

Given below is the standard set of information required for filing a dental claim. Each claim that you submit to payers needs to include the following:

1. The Subscriber’s ID.
2. The name of the patient, his/her date of birth, and relationship to the Subscriber.
3. The name of the dentist or practice, Tax Identification Number or Social Security Number, National Provider Identifier (NPI), and phone number;
4. The procedure code number as per the American Dental Association (CDT), the treatment date, tooth number, tooth surface(s), the doctor’s fees, and a narrative or description of services as deemed necessary;
5. The Member’s signature for the release of information and/or assignment of benefits. The Dentist’s signature.

It is vital to do everything a practice can to avoid denials in order to protect the financial health of the practice, and its reputation as a preferred place to work and perform dental care procedures. Here are some measures that can be taken to avoid delays and denials while filing for dental claims:

1. Map out your dental insurance claims process workflow in detail to streamline it.
2. Identify the insufficiencies in your claims process, in order to fill in any gaps discovered.
3. Reduce errors in data entry by double-checking the patient information.
4. Choose electronic forms over traditional paper forms to collect patient information.
5. Promote the use of templates to record clinical notes so as to ensure uniformity and clarity in data collection.
6. Make sure claims are submitted including all the relevant imaging, else there is a risk of rejection.
7. Carry out frequent evaluations of your process to ensure they are up to date.

Conclusion:
There is no doubt that managing dental insurance claims is a distressing task for a lot of dental practices. However, staying on top of the collection game needs to be top priority for all dental practices alike. The better a practice gets at submitting claims successfully, the sooner its accounts receivables get converted into cash, and the healthier the cash flow of that practice becomes. Since a good claims process in place can affect the profitability of a dental practice to such an extent, it is crucial that all collection issues be addressed at the earliest.

Each year denied and rejected claims result in revenue loss in the millions for hospitals and private practices. This results in undue stress to a provider’s revenue cycle management. Unfortunately, both large and small dental practices, also, find it rough going due to denied claims. Despite this, a lot of practices do not appeal their denied claims because they lack time or do not know whether the claim is truly appealable. A majority of a practice’s active patient base are those with dental insurance, so not appealing  claim denials can be expensive.

Appealing denied claims isn’t exactly a cakewalk though and keeping up with the frequently changing rules and regulations can be cumbersome. Updated rules, contracts, terms, and conditions serve as catalysts for dental insurance companies to delay or reject insurance claim reimbursements.

Circumventing this situation is mandatory for a robust revenue cycle, and the first step involves understanding the reasons behind claim denials.

Here are some common reasons for claim denials:

Late filing of claims

Most insurance companies provide a timeframe within which claims need to be filed. Any claim submissions after the given timeframe leads to claim denials.

Procedures deemed medically unnecessary

Some procedures may be considered medically unnecessary by the insurance company you are submitting the claims to.  This is yet another reason for claim denials. 

Frequency limitations

If a request to perform a procedure is sent after the coverage period has ended, chances are, it will not be covered by the insurance provider, leading to claim denials. 

Exclusions in insurance plans

Some insurance plans may exclude certain procedures, leading to claim denial if the filed claim includes those procedures and the payments for these tend to go unpaid. 

Plan maximums

Each plan is covered for a certain amount per benefit period. This benefit period is usually for a year – calendar or fiscal. Insurance companies will not reimburse claims, leading to claim denials, if this annual maximum amount has been reached during that benefit period. 

Incorrect CDT codes

The Code Maintenance Committee (CMC) at the American Dental Association (ADA) makes revisions, deletions and updates to the existing CDT codes set every year. Filing claims without factoring in these updates is also a reason for denied claims.

Up-coded and Bundled or Unbundled services

Up-coding a service to get a higher reimbursement, unbundling of services to get additional reimbursements or bundling services to save time are also reasons for an insurance company to deny claims. Some plans may also have clauses inserted to ward off such practises. 

Once the reason/s for denial has been identified, an appeal can be filed against such a denial. Submitting appeals, though possibly onerous, is not impossible.

So, here are some ways to make your claims appealing easier:

Confirm the reason/s for denial

There may be multiple reasons for claim denials. Before starting the appeal process, make sure you confirm that all the reasons for the denial have been identified. Examine the insurance coverage to spot any mistakes; procedures and services that are covered will be specified in the plan. It will also include a list of any restrictions or exclusions that the insurance company has stated as not covered. 

Call the insurance provider if needed

When in doubt, get in touch with the insurance provider. This should ideally be done before you begin the appeals process. It gives your practice the opportunity to get additional details directly from the source and reduce chances of claim denials.

Categorize denials

The appeals process for claims can be streamlined, and patterns in denials can be found by categorizing them. Strategies can be designed, and appeals can be done in a more detailed and accurate way, avoiding similar mistakes. Having an efficient denial management system in place can help you achieve that.

Appealing claims on time

Just as in the initial filing of a claim, a majority of insurance providers specify timeframes for practices to submit appeals on denied claims. Depending on the insurance provider, this timeframe can vary anywhere between 90 days to 1 year. Therefore, make sure that your appeals are submitted within this timeframe. 

Follow-up on appealed claims 

Set reminders to follow up on each claim appeal periodically. If you have contacted the insurance provider before beginning the appeals process, ask for a turnaround time to know when you can follow up for a status check. Checking on the status of an appeal can help you make sure that the claims do not slip between any cracks.

Although these tips will, undoubtedly, help you improve your appeals process, the preferred thing to do would be to avoid claim denials as much as possible. 

Some steps you can add to a checklist when you submit your initial claim are: 

• Scrutiny of the benefits
• A thorough understanding of the terms and conditions of the insurance coverage
• Patient education regarding potentially limited benefits
• Verification of the service date
• Documentation of all necessary information required to be submitted by the insurance provider
• Use of accurate CDT codes
• On-time claim submission

While appealing on rejected or denied claims can be time-consuming, the process is indispensable when it comes to generating revenue and bolstering the financial health of a practice. 

After providing dental services to a patient, billing of claims follows as a matter-of-course. Claims billing has become a complicated process today. Different carriers, their various software infrastructure, different clearinghouses and their requirements, federal and state mandates, the myriad amounts of data and documentation required for preparing claims, all could make claims billing and submission quite confusing. Add to that the different types of services that patients may avail from a dental practice, and you have virtual chaos on your hands. Errorless claims billing, among other things, sets the foundation for the revenue cycle management of dental healthcare. Without a proper billing system, practices could find themselves disoriented. 

So, how can you make your claims billing easy?

Transparent Communication

Before any service is provided, every practice needs to ensure that information regarding services and payments is communicated to their patients. Transparency in communication is a crucial and one of the simplest and most effective ways to improve your claims billing process. Your patients need to be made aware of their responsibilities and data collection requirements, before availing the services. This ensures, firstly, that the patients are not subjected to any surprises about information or payments that they are responsible for. Secondly, it prevents the possibility of denials or part payments due to ignorance about the requirements within the claims process. Such information is especially required for services that are only partially covered or those that require copayments. Organizing your data and pieces of information that need to be given to your patient, will improve the chances of building a better bond with your patients, thus increasing the reliability of the practice.

Maintain and Update Patient Files

It is important that you keep your patient files updated at all times, as any inaccuracies in them can lead to wasted time and revenue losses. A change in insurance carriers, type of plan, demographics, services covered, copays and deductibles are all examples of the types of information that could change even mid-term. If such information is not updated on time, the revenue cycle gets disrupted. All such changes must be collected, verified thoroughly and updated regularly before the submission of claims. It follows that the first step to having a well-managed claims billing process is to have an up-to-date patient information file.

Maintain Sufficient Documentation

Documentation here refers to what is prepared for each service provided. Timely reimbursement depends hugely on proper and sufficient documentation. Each carrier would have different documentation requirements for claims. Some may even require additional documentation for specific procedures. Identifying what is required and ensuring that it is ready and accurate can drastically reduce the need to resubmit claims due to denials or part payments. 

Keep in touch with the patients as well as the insurance provider

Stay in touch with your patients as well as the insurance provider in case any additional information or updates on already existing ones is required. This ensures that you keep the channels of communication with your patients and insurance providers open, which, in turn, facilitates the chances of receiving important updates on all the necessary information needed for claims billing. 

Stay Up to date on Coding Regulations

A huge number of claim denials occur because of incorrect coding of the services rendered. This is a natural probability given the sheer volume of codes there are in the dental insurance field. Any change to the coding rules and regulations amplifies the problem. Staying up to date on coding changes, additions and/or deletions can save your practice the time and energy needed for reworking denied claims.

Tracking Frequencies, Exclusions, and Limitations

Usually, frequencies, exclusions, and limitations vary according to different insurance plans. The payment amounts available depends on these factors. There may be policies that even have age-group limitations for certain procedures. It is, therefore, crucial to obtain a copy of the patient’s information as well as an insurance certificate that details exclusions, age limitations, and plan benefits before the claims billing process.

Quality Control

Establishing quality control measures for claims submissions is a wise decision to make. It strengthens your claims billing process, wipes out any potential errors, and helps you cut out any unnecessary expenses. In addition to this, there is quite a bit of learning to be had in reviewing any past claims that were denied. This will help eliminate the same errors being made in future. 

Partnering with an RCM service provider

Claims billing is one of the most important and crucial steps in the dental revenue cycle management process and therefore requires a lot of attention and focus from the staff at your practice. It is only natural that not paying enough attention to it would cause negative impacts on your RCM. An RCM service provider mitigates the stress that is involved in running a practice. Your staff and you can focus entirely on patient care and treatment, while your RCM provider guides you through the complex revenue cycle processes. A competent RCM provider helps you create a well-planned and organized system to maintain a healthy revenue cycle.