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10 reasons your dental insurance claims are being denied

Originally published on the Dental ClaimSupport Blog.

One of the more frustrating aspects of dentistry is simply dealing with insurance companies and claim denials. Having to deal with dental insurance billing is such a hassle, especially when claims are delayed or denied entirely. You can’t help but ask yourself, “what the heck am I doing wrong?”

If there’s anything we at Dental ClaimSupport understand, it’s the frustration of a denied claim. That’s why we’ve made it our mission to help dental practices get their claims appealed and paid. We’ve spent years uncovering the best practices to successfully get insurance claims paid quickly and smoothly.

Claims are usually denied because of small, easy-to-miss mistakes. Once you realize how easy these mistakes are to make, you’ll also see how easy they are to fix. In this article, we will uncover 10 reasons your claims could be getting denied by insurance for reimbursement. 

Understanding these mistakes can help your dental team avoid them in the future, in order to get insurance claims paid so that your practice can collect what it’s owed. Let’s dive into the 10 reasons for claim denials.

1. Incorrect dental codes

In order for a dental claim to be processed properly, it’s necessary to include the correct, current code set to identify the diagnosis, services rendered, and procedures performed. This could be either a CDT code or ICD-10-CM. 

Making mistakes on codes is probably the easiest mistake to make because codes are hard to keep up with. They update and change every year. 

Here’s what you can do:

Make learning the dental codes your priority. Invest in your education of CDT and ICD-10-CM to avoid making coding mistakes. You can enroll in Dental Claims Academy to deep dive into your dental coding education. 

2. Outdated insurance claim forms

Did you know you have to have up-to-date claim forms? Dental insurance companies will update their claim forms and what information is needed from time to time. It’s important to stay on top of when this happens so that you are not sending outdated claim forms that lead to denials. 

Here’s what you can do: 

For a smoother, and possibly quicker, process, always use the most recent version of claim forms. If you’re having doubts about which version of a claim form to use, call the insurance company and double-check. Verifying which form to use when sending a claim might take you a few minutes on the phone, versus sending a claim on the wrong form, getting it denied, then having to re-send the claim. 

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3. Incomplete or incorrect information on the dental insurance claim

This might seem like a no-brainer, but it’s one of the more common ways that dental insurance claims are denied. It’s pretty easy to misspell someone’s name, input the wrong insurance number, or any kind of input error. It might have not even been an input error, maybe your patient has updated some of their information and didn’t tell you.

This is why you always ask if any of their personal information (name, address, or employer) has changed since they last came to the dentist. 

Here’s what you can do:

Make sure whoever is responsible for creating and sending claims is not distracted by anything else. They should always have time set aside, dedicated to accurately filling out the claims. They should have the time to double-check that all slots and blanks have been accurately completed on the claim forms. 

When we say “have the time” we mean they do not have other pressing responsibilities that could distract them or take away from the time spent accurately creating, batching, and sending claims. 

4. Not Reviewing patient benefits (insurance verification)

This goes hand-in-hand with the previous issue. It’s good practice to have your receptionists ask for a run-down of the patient’s benefits; although their insurance company may be the same, the benefits and/or group number may be different. 

Here’s what you can do: 

A key step to making sure insurance claims are not denied is insurance verification. Reviewing a patient’s benefits before they enter the office is the best way to make sure all of their information is up-to-date, their benefits are still active, and just how much of the procedure their insurance will cover. 

5. Unreadable information and files

As insurance companies and dentist offices transition to electronic information, a common problem that arises is unreadable information/files. If the writing is too light or smeared or simply illegible, this can result in insurance claim delays. 

Here’s what you can do: 

A great way to ensure your claims aren’t denied is by having great quality images and x-rays attached to your claim. An intraoral camera can help with this. This camera will produce a color photo showing what the naked eye sees. Therefore, it clearly conveys the condition of the patient’s mouth, which is of course always needed for an insurance claim. 

Also, when submitting x-rays or charts, be sure to send the correct version; also make sure that they’re mounted, labeled (right/left), and readable.

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6. Missing tooth clause

In this situation, a patient comes into your office with a missing tooth, claiming that he has dental insurance. You file the appropriate insurance, but the insurance company denies the claim because “the missing tooth was extracted prior to the patient’s dental coverage and its replacement is not a covered benefit.” 

Here’s what you can do: 

The best way to avoid this issue is to know the patient’s benefits before doing anything, especially complex procedures. This goes right back to insurance verification. Make sure you and the patient aren’t missing any “fine print” information, specifically about the time during which the tooth was extracted. 

We can’t emphasize enough how important it is to verify insurance before the procedure is performed. It helps avoid a lot of confusion and surprise bills to your patient

7. Contractual denials: clinical and limitation

Contractual Clinical Denials occur simply because some contracts don’t cover certain services; usually, non-coverage services include cosmetic procedures. Contractual Limitation Denials are delayed or denied due to limitations in the contract based on age, frequency (how much time must pass before doing more procedures on the same tooth), or waiting periods.

Here’s what you can do: 

Not only do you need to verify the patient’s insurance benefits before the procedure to make sure the benefits are active, but you need to understand what will and will not be covered. If the patient wants a whitening procedure done, you need to see if their benefits will cover a cosmetic procedure such as this. You also need to understand the rules of their benefits as far as frequency and waiting periods go. 

It falls on the shoulders of the practice to know the ins and outs of the patient’s benefits because patients will likely never fully understand their own benefits. It’s an unfortunate truth. 

8. No explanations on the claim form

If you can’t explain or document a reason why a procedure needs to be done, chances are slim that the insurance company will approve the claim. You must always have an explanation of why a procedure was performed, and this explanation must be detailed and personal to each patient. 

We see offices have claims denied (or even get into legal trouble) because they use stock narratives on their claim forms. This means a pre-written or a default explanation of why a treatment was needed. Make sure you avoid this as well as leaving off the explanation altogether.

Here’s what you can do: 

We’ve said it before, we’ll say it again: make sure one person has the time to be dedicated to creating insurance claims. 

Neglecting to add an explanation of treatment to claim forms or adding a “default” explanation is a really quick way to have your claim denied. 

Make sure the person responsible for insurance claims isn’t forgetting crucial information due to being spread too thin at the office.

9. No student verification

Inadequate documentation of a student’s status often leads to denied or delayed claims. You guessed it, this goes right back to insurance verification. If the student status of the patient is going to affect their insurance coverage, it’s important you review the patient’s benefit plan to better understand it before the procedure. 

Here’s what you can do: 

Ask the patient’s insurance carrier to gain a better understanding of what information you’ll need regarding their status as a student. Like we said above, it only takes a few minutes to call insurance and ask a simple question of how their student status will affect their benefits versus waiting to receive a denied claim and resubmit a new claim in order to have it paid. 

We’re talking minutes versus weeks. 

10. Trying to juggle everything

Last but not least, claims are denied because the person (or people) responsible for sending claims is juggling too much. All of these reasons can boil down to this final reason for claims being denied. Mistakes happen and everyone is human. Filling out claim forms is a tedious task, and making sure they are batched and sent accurately is a time-consuming process. 

If you are also trying to check-in patients, answer phones or keep up with a schedule, it’s easy to make these mistakes. 

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Here’s what you can do: 

There are really two options here. You can either hire an insurance coordinator, whose only job is handling your insurance billing and will not have any other pressing responsibilities, OR you can outsource a dental billing company, where a billing expert will be dedicated to getting your office’s claims paid. 

Whichever you choose, you need someone accountable for seeing a claim through from start to finish. 

Submit your dental insurance claims without fear of denials 

Repeatedly receiving claim denials from insurance companies is really frustrating. Your dental practice is missing out on money it has earned, and figuring out why your claims are being denied can feel like a wild goose chase. 

After reading this article, you should now have a better understanding of why some of your claims could be getting denied by insurance companies and how to combat the causes of denials. A solution that could help all dental practices, big or small, would be having a single person dedicated to your practice’s insurance billing. 

As we mentioned, this could be an insurance coordinator or an outsourced dental billing company. Dental ClaimSupport is a great resource not only for learning more about how to get your claims paid quickly but also for learning which option (outsourced billing or in-house billing) is best for you. 

Either could be a viable option for your practice. Figure out which solution is right for your practice by reading our article, “The cost of outsourced dental billing vs in-house dental billing.”

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