Roy

Roy Shelburne

Dental Consultant

7 Deadly Sins of Insurance Claim Denials

With nearly 65% of dental practices participating with dental insurance, dental insurance billing is a crucial element of revenue cycle management. Let’s explore the 7 most common claim issues that lead to denials and delays, and how to avoid them to have steadier cash flow.

1. Inadequate reference materials

Insurance codes change and update every year. Do you know what that means? Changes in requirements, and if dental billers are not apprised then it opens the door to denied funds to your practice. This is where billing & coding reference materials are crucial. Investing in current, complete, and accurate billing reference materials each year will improve claim reimbursement, treatment planning, and more.

The industry’s leading coding resource is Coding with Confidence by Dr. Charles Blair. This resource is guaranteed to help dental billers confidently send the proper, updated code on the claim — with all of the required documentation — for timely reimbursement. 

2. Inexperienced or inadequately trained team

Hiring is hard — period. Hiring someone with the knowledge that you need to ensure the success of your dental practice can feel impossible. Then, once you have hired someone, your training and onboarding process may not be entirely effective. Here are some ways you can invest in education and training for your team:

  • Encourage growth and continued education
  • Look for lifelong learning mindsets in team members
  • Trust, but verify 
  • Give praise and celebrate growth and improvement

If you are feeling defeated with the hiring process in your area, consider outsourcing your dental billing processes to a trained team. This allows you to hire for office culture instead of specialized hard-to-find billing expertise. 

3. Documentation that is nonexistent or inadequate

The hard truth is that if it’s not documented, it didn’t happen. Inadequate documentation can directly result in reduced reimbursement. If the documentation is not sent with the claim to back up the services rendered, the claim is in danger of being downgraded or outright denied. This also increases risk, prompts insurance company audits, and could lead to prison time. 

Using the SOAP method when writing your clinical notes helps keep claims “clean” — pun intended. Unfamiliar with the SOAP method? We’re here to help.  

4. Inaccurate fee schedules

Are you noticing that the fees on the patient’s ledger and the fees on the EOB don’t match? Updating fee schedules regularly reduces unnecessary debits and credit to patient ledgers and helps with treatment plan presentation. The best part is that you can do it efficiently through your practice management software to consistently update across all patients with those insurances. 

Here’s a pro tip: 

If all participating dentists send the PPO fees on the claims, reimbursement from insurance is very unlikely to increase. Update the PPO fee schedule to accurately show on the patient ledger, but bill the UCR fee to the insurance company. This will give you more accurate monthly production numbers and potentially leads to increased reimbursement. 

5. Inaccurate claim information

Insurance denials due to incorrect claim information are the mother of all denials. Even the smallest error on a claim can cause delays, denials, and roadblocks in revenue cycle management. We can’t always expect patients to tell us exactly what insurance they have or exactly what it covers, so develop a pre-appointment readiness plan to reduce unexpected denials and improve treatment plan estimates. 

6. Incomplete narratives and/or supportive information

Remember “clean” claims from sin #3? A “clean” claim has all of the accurate information and supporting documentation to show treatment was necessary and rendered. This means knowing what the insurance payors want with a claim before they ask for it. Unsure? Send it anyway. There is no such thing as too much supporting documentation. 

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Sending “clean” claims daily, with all of the necessary supporting documentation, ensures timely reimbursement and steady cash flow for your practice.

7. No system to monitor and follow-up on all open claims

This one’s hands down the most common sin that we’re all guilty of making. Develop a clear plan of action to get the outstanding insurance accounts receivable off the books and in the bank. Communicate and involve the entire team in the dental billing process, as each team member plays a key role in successfully sending a “clean” claim for payment. You can utilize your morning huddles for this communication. 

A follow-up to this sin is not knowing when to ask for help. Some claims really are out of this world, but that doesn’t mean we can’t find help to get them paid. If you’re feeling stuck, behind, or with your nose too far onto the grindstone, discover peace of mind with eAssist. We promise to support you from day one and, best of all, we don’t replace your current staff. Focus on the things that truly matter in your office and rest easy and profitably knowing that outsourcing your dental billing doesn’t need to be as scary or confusing as your outstanding insurance A/R may be.

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