When any patient walks into your office with dental insurance, several steps must be taken to make sure you are compensated for your work. Insurance is a business just like any other. We all know they are in it to make money, right? Of course they are! And for these reasons, getting your patient’s dental insurance claim paid can sometimes be a little more difficult than one might think.
Here are three proactive steps you can take for your claims to be processed and paid as quickly as possible.
1) Verify eligibility and coverage details
This is the most important, yet most tedious job in running the day-to-day of a dental office. When you verify eligibility and benefits, you’re assuring yourself that this patient has coverage, and most importantly, has coverage that can pay you. You want to check and see things like their service history, percentages for preventive, basic, major, and ortho services.
You also want to check on frequency limitations, waiting periods, and missing tooth clauses. All of this will help you collect from the patient upfront. Meaning, you know exactly what insurance will pay (without having to send a pre-determination), and exactly how much the patient will owe you (if you have successfully entered in your PPO fee schedule.)
When checking eligibility, you want to verify other things relating to the insurance as well. You will want to research the following:
- Amount of the deductible and how much has been used
- Plan maximum and how much has been used
- Payer ID for the insurance
- Claims mailing address
- Relationship to subscriber
- Plan effective date
2) Submitting dental claims
This is what makes or breaks the dental claim getting to the insurance and being paid by the insurance. There are a total of 58 boxes on a claim form that must be accurate for each claim to process. You heard correct, 58! These boxes are automatically filled out by your practice management software (PMS), so you must make sure everything in your PMS is accurate. These things include, but are not limited to:
This must be entered accurately in your PMS. The insurance information I am referring to is the name of the insurance company, the claims mailing address, and the claim payer ID. The claim payer ID is a specific code used by the clearinghouse and insurance that tells the clearinghouse which insurance company the claims needs to be sent to. If the payer ID is entered incorrectly and the claim is sent electronically, chances are the claim will not be on file when you check the status of it 30 days later.
Patient name, address, date of birth, and ID must be exact for the claim to be accepted by the insurance. These are entered by your front desk when the patient completes their registration forms.
Procedures must be coded correctly. Time and time again, claims kick back in the clearinghouse due to miscoded procedures. The code we see the most being miscoded is posterior composite coding and anterior composite coding. Sometimes we’ll see a 3 surface code with only 2 surfaces, or an anterior tooth have the posterior code and vice versa. These are easy fixes for any dental office but are the most popular reason claims like to kick back in the clearinghouse.
Rendering and billing provider information must be accurate and up-to-date with the insurance company. Insurance companies will not pay some John Doe off the street they have never heard of or have no information for. You must credential each provider with your practice with each insurance company. If the provider rendering services is not affiliated with your practice, they will deny the claim, kick the claim back saying they can’t locate provider records, or pay the claim out-of-network and sometimes mail the payment to the patient!
3) Claims processing
There are several different things that can happen with the claim after the claim has been submitted, but I want to talk about the most common three.
Congratulations! Everything was entered in your PMS correctly. The coding was correct, the patient information was correct, the insurance information was correct, and you verified the patient’s service history to know what you could and could not perform. You receive an Explanation of Benefits either electronically, or through the mail. You post the payment by line item showing how much insurance paid on each procedure, you take the correct PPO adjustment (if needed), the patient has a $0.00 balance and you’re done! If the patient has something other than a $0.00 balance, no need to panic! Studies show, if you reach out to the patient within 30 days of their date of service for payment, they are much more likely to pay than anytime after 30 days. So, just simply reach out to the patient for their portion or collect it on their next appointment if it’s within the week (but you can still give them a courtesy heads up.)
When a claim denies, it’s not the end of the world. If you verified your insurance correctly, you shouldn’t have many denials, yet they are still bound to come. When a claim denies requesting additional information, do not close the claim. If the insurance company is requesting additional x-rays, a narrative, a perio chart, etc. you can print out what they are requesting and mail it back with the denial EoB and a new corrected claim. You always want to send in the initial claim number on the remarks section of the new claim, so it will not deny as a duplicate. If the insurance company denies needing something from the member (coordination of benefits information, copy of divorce decree, evidence of employment, etc) you will need to contact the patient and have them reach out to their insurance. If the patient is unwilling to do so, they are ultimately responsible for their insurance and will need to have their claims closed and be made responsible for their balance.
No response from the insurance
By law, most insurance companies must send you some receipt notifying you they received your claim within 30 days. Either an EoB, denial EoB, or a letter stating they have received your claim will be sent to your office. If you do not receive one, chances are the claim is not on file. You must contact the insurance and figure out what went wrong and why the claim is not on file, or what’s the hold up with your claim’s processing. Maybe the ID entered was off by a number, maybe the DoB is incorrect, or maybe it’s the insurance stalling and not wanting to pay on your claim. Regardless of the reason, if your claim is not on file, you need to have this claim re-submitted with the updated information. You can submit a claim 4 different ways. You can re-submit the claim electronically with the updated information, you can print the claim and mail it to the address they give you, you can fax the claim, and you can submit the claim through the online portal if the insurance has this feature. If the insurance does not allow you to submit claims through an online portal, I suggest faxing, mailing, and electronically sending the claim. If the insurance receives all three, one will process and the other 2 will deny as a duplicate.
In conclusion, following these steps will drastically eliminate the headache and stress associated with dental insurance. Learning the ins and outs of dental insurance is a process, and not something you master overnight. Following these steps will ensure your practice gets PAID from insurance companies and you collect what you produce. However, if you struggle to find the resources to maintain this flow, please feel free to give us a call!
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