What should I do???

What should I do???

This is a question that a lot of Office Managers or Dentists find themself asking when they receive an EOB stating that a claim has been denied by insurance.  There are several reasons a claim may be denied and there is always a way to appeal or send a corrected claim to get the claim paid without raising a RED FLAG to the insurance.  For instance, let’s say that you had a patient in for their 6 month routine cleaning and insurance denied the claim due to it being 1 day too soon per their policy. Your best option to not defraud the insurance, would be to send an appeal stating the reason why the patient was in a day earlier than allowed and ask to make a one-time consideration for the error in scheduling or whatever the reason may have been.   To prevent that from happening in the future, ensure that when scheduling recare, you schedule it 6 months and 1 week later. It would not be legal or ethical to change the date on the claim in order to get the claim paid. With the original claim already being denied, this would raise a RED FLAG for insurance and they will watch for a pattern for future claims submitted.

It is important as a dental office, to ensure that you submit only the treatment you provide with all of the supporting documents to receive payment from insurance and not make changes if claims are being denied.  All insurance companies have different policy provisions they follow and as a dental practice, it is important to know what the plan provisions and limitations are in order to utilize a patients benefits accordingly. For example, some insurance companies will only allow 2 quads of SRP to be done in one day and it would be unethical to do them all in one day, but change the dates in the chart in order to get paid by the insurance.  

To prevent claims from being denied, it is in the best interest of the practice and your patients to ensure you get a full breakdown of benefits and the limitations of the plan to ensure treatment is rendered according to the guidelines to prevent any issues with claims getting paid.  We all know we don’t like to have upset patients due to claims being denied, but changing any information in order to get it paid would be insurance fraud and could cause a larger issue for any dental practice and the staff involved.

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