10 reasons your dental insurance claims are being denied

Dealing with insurance companies and denied claims is one of the most frustrating parts of being a dentist. It's such a pain to deal with dental insurance billing, especially when claims are delayed or denied. You have to wonder, "What the heck am I doing wrong?"

At Dental Claim Support, if there's one thing we know, it's how frustrating it is to have a claim turned down. So, we've made it our goal to help dental practices get their claims paid after they've been appealed. We have spent years figuring out the best ways to get insurance claims paid quickly and easily.

Most claims are turned down because of small mistakes that are easy to miss. Once you see how easy it is to make these mistakes, you'll see how easy it is to fix them. In this article, we'll look at 10 reasons why your insurance company might not pay out on your claims.

If your dental team knows about these mistakes, they can avoid making them in the future. This will help get insurance claims paid so that your practice can get the money it is owed. Let's look at the top ten reasons why claims are being turned down.

 1. Incorrect dental codes 

So that a dental claim can be processed correctly, it needs to include the correct, up-to-date code set for the diagnosis, services provided, and procedures done. This could be an ICD-10-CM code or a CDT code.

Because codes are hard to keep up with, making mistakes with them is probably the easiest mistake to make. Every year, they change and get better.

2. Outdated insurance claim forms

Did you know that your claim forms have to be up-to-date? From time to time, dental insurance companies will make changes to their claim forms and the information they need. It's important to know when this happens so that you don't send out claim forms that are too old and get turned down.

3. Incomplete or incorrect information on the dental insurance claim

This may seem obvious, but it's one of the most common reasons why dental insurance claims are turned down. It's pretty easy to misspell someone's name, put in the wrong insurance number, or make any other kind of input error. It might not even have been a mistake on your part; your patient might have changed some of their information without telling you.

This is why you always ask if their name, address, or employer has changed since they were last at the dentist.

4. Not Reviewing patient benefits (insurance verification)

This goes along with the last problem. It's a good idea to have your receptionists ask about the patient's benefits. Even if they have the same insurance company, their benefits and/or group number may be different.

5. Unreadable information and files

As insurance companies and dentist offices switch to electronic information, files and information that can't be read are a common problem. If the writing is too light, smudged, or just hard to read, it could delay your insurance claim.

6. Missing tooth clause

In this case, a patient comes to your office with a missing tooth and says he has dental insurance. You file the right insurance claim, but the insurance company says "the missing tooth was extracted before the patient's dental claims coverage, and its replacement is not a covered benefit."

7. Contractual denials: clinical and limitation

Contractual Clinical Denials happen because some contracts don't cover certain services. Most of the time, cosmetic procedures aren't covered. Contractual Limitations: Denials are delayed or denied because of limits in the contract based on age, frequency (how much time must pass before doing more procedures on the same tooth), or waiting periods.

8. No explanations on the claim form

If you can't explain or prove why a procedure needs to be done, the insurance company is less likely to pay for it. You should always know why a procedure was done, and the reason should be detailed and specific to each patient.

We see offices get their claims turned down or even get in trouble with the law because they fill out their claim forms with stock stories. This means a ready-made or default reason for why a treatment was necessary. Make sure you don't do this, and you can also just skip the explanation.

9. No student verification

When there isn't enough proof of a student's status, claims are often denied or delayed. You guessed it, this is all about making sure the insurance is correct. If the patient's status as a student will affect their insurance coverage, you should review their benefit plan before the procedure to learn more about it.

10. Trying to juggle everything

Last but not least, claims are turned down when the person or people sending them have too much on their plate. All of these things can be summed up in this last reason why claims are turned down. We are all human, so we all make mistakes. Filling out claim forms is a tedious job, and making sure they are sent out in the right batch and in the right way takes time.

It's easy to make these mistakes if you are also trying to check in patients, answer the phone, or keep up with a schedule.

The Right Medical Denial Management Strategy

There have been changes in the payment methodology, and with the Affordable Care Act (ACA), we are witnessing a paradigm shift in the healthcare landscape. Unfortunately, despite the patient-centric care model and value-based services being at the core of this new development, the healthcare industry loses about $262 billion in claim medical denial out of $3 trillion. This figure translates into each provider denying $5 million on an average. The right medical denial management

Strategy can help you to ensure no medical denials:

But the biggest thought is “Why are these figures important?”

When such figures are so massive in a claim medical denial, it won’t be far-fetched to think you can get denied by the provider. Unfortunately, it means you will be losing the revenue like hundreds of other practices despite rendering the services.

However, there are ways to combat claim medical denial with a proper medical denial management strategy. As a practice, you need to be proactive instead of reactive when it comes to medical claims management.

The right strategy can help you with the following and ensure few to no medical denials:

A solution at the beginning

Did you know? A part of the medical denial management system ensures that your staff are registering the patients with the right details required for getting the 100% reimbursement. It will include the gathering of all the correct details that your practice would need to file the claim for your services.

Ensure meeting the deadlines

When the right medical denial management strategy is in place, an accurate system will automatically be developed as a part of your medical billing process that will maximize your practice workflow’s efficiency. It includes keeping the entire paperwork ready and submitting the medical claims on time. In fact, one of the common causes that lead to claim medical denials is missing the claim submission deadline.

Understanding the claim medical denials

Even when you have everything right with all the correct information, there can be instances when your medical claims are denied. Therefore, a part of the medical denial management strategy wants you to understand the root causes of the medical denials instead of just assuming its reason. Such a medical denial analysis will help you further to predict any future rejections under similar circumstances and mitigate them as soon as it arises.

Stopping the claim pile-ups

It is quite easy to lose track of the medical claims denied in the manual system, letting them to pile up. In fact, it can quite be a difficult job for a practice like you to keep a track of the loss of such revenue due to claim pile-ups. All thanks to an automated claim management system software that can be put in place to keep an accurate track of the denied medical claims and consequences arising income. It will help you to streamline the medical denials and undertaking of the resubmission process to help in mitigating the revenue loss.

Improves the revenue collection

A proper claim medical denial management strategy can help in boosting the overall revenue collection of your practice. In addition, the automated streamlining medical billing and coding process will help you to improve the workflow, and the resubmission of the medical claims denied while keeping a track of those that your practice fails to collect timely from the insurance providers. Thus, it helps your practice to maintain its profitability level.

Identifying the issues

With the automation medical claims management system software and analytics, you can quickly check daily analysis reports. This will help your practice to identify any issue related to medical claims at the earliest and take care of it immediately before such a claim medical denial-related problem escalates. Moreover, it also allows you to identify the areas in your practice that can cause revenue loss.

Keeping up with changes

As we all know that medical billing rules and regulations are constantly changing, and you must keep up with such trends. In fact, one of the inherent reasons that lead to claim medical denials is the failure to stay abreast with these changes. Again, all thanks to the right medical denial management strategy as it can immediately notify you about the changes happening in the medical billing and coding landscape so you can implement them. In addition, the automated claim software can be updated with such new developments to file the medical claims accordingly.

Despite the complex system of claim lodging that often leads to claim medical denials, it can be prevented with the right medical denial management strategies. Such a process starts with knowing the reasons for the claim medical denials, thereby training the practice staff to ensure that it does not happen again. Though you can do the entire process in-house, it doesn’t guarantee complete success keeping in mind the time, efforts, and money involved. That’s why it is usually recommended to take the help of a professional medical billing and coding company known for implementing a full-proof claim medical denial management system into the practice. You can Ajust Solutions for helping you in putting the right claim management strategy in place for your practice.

More Info Click Here: Appeal Medical Claim