How To Process Dental Insurance Claims?

From the moment a patient is registered until the explanation of benefits (EOB) and payments are finished, dental claims processing include all phases of providing care to patients. Dental insurance claims can be submitted both on paper and online.

How do dental claims work?

Your dental insurance provider will review your claim after it has been properly submitted to ensure that the procedures you received are covered under your plan. If the insurance company approves the claim, they will send the proper reimbursement to your dentist for the services you received. However, if you pay the cost in full up front, the insurance company will reimburse you.

If you make a claim and your insurance carrier doesn’t cover part or all of the services included in the claim, things could get complex. In this instance, your dentist will most likely call you directly to request an out-of-pocket payment. Alternatively, your insurance company may contact you about any payments you owe your dentist because they don’t cover the entire cost of treatment.

What are the different methods for filing insurance claims in dental?

Dental insurance claims can be submitted both on paper and online. Claims go through numerous phases once a patient visits a dental professional before the patient receives their final bill:

Is dental billing hard?

As dental practices undergo major computerized transformations, changing the way dentists record and track patient health remains a major problem for billing managers. Then there’s the matter of getting paid.

Collecting bills has never been simple. Unpaid medical bills account for 52 percent of collection services, according to the US Consumer Financial Protection Bureau. About 43 million people owe money on their medical bills, illustrating the difficulty that a practice faces in collecting money from its customers. Medical and dental billing might be a difficult procedure, but it is not insurmountable.

Copays are payments made in advance for services rendered by caregivers. If physicians do not receive the full amount up front, they may have difficulty obtaining the remaining portion of the patient’s payment. According to studies, the possibility of collecting from a patient diminishes by about 20% the moment the patient leaves the clinic.

To avoid losses, require front desk employees to be transparent about the practice’s collection policies and ask for a credit card to settle patient copays at check-in before the appointment. A down payment on top of the deductible may be required for amounts not covered by insurance.

It is better for both the patients and the practice to collect fees and copays at the time of treatment. A high cost following a treatment might be intimidating, and paying it is usually more difficult. Collecting copays before providing services is how a strong business grows, whether it’s in a doctor’s office or a dentistry practice.

Because most dental practices cannot afford to write off unpaid copays, this is not a practical solution. If each clinician sees 12 patients in a normal office with two doctors and one assistant, and the average copay is $25, that’s $900 in copays to collect per day. In this case, the clinic is open 200 days a year, resulting in a total potential copay collection of $180,000 for the year.

Before a patient walks through the door, they should double-check their insurance coverage. Before providing services, practice administrators must make an effort to verify coverage. While this may add to the team’s administrative workload, it can help to prevent revenue loss and billing concerns in the future.

Prior to executing a high-cost surgery, the physician should understand the patient’s insurance coverage to see if there is anything the patient would have to pay for out of pocket. Many people cannot afford to pay for their portion of the operation.

Similarly, some patients may believe that a procedure is entirely covered by insurance, but they are responsible for the portion that is not. Knowing this allows you to better prepare people for procedures and offer a payment plan.

According to the Medical Group Management Association, 94% of medical practices provide payment plans to their patients, but only 25% do so at the time of service. As a last resort before a debt is sent to collections, about 45 percent of clinics offer payment arrangements. The majority of dental offices work in a similar manner. Payment plans can help guarantee that treatment is completed while also allowing the patient to handle affordable payment arrangements.

Teresa Duncan, the founder of Odyssey Management, is a dental coding expert who routinely speaks to audiences on changes in dental coding. She emphasizes that the materials and technology utilized in dentistry for surgeries and implants are continually changing.

As new materials and techniques become available, the requirement for code to support them increases. Annual coding updates, which are provided once a year, can keep even the most seasoned practice managers on their toes. Codes are frequently updated to improve clarity or to specify newly additional areas of treatment coverage, such as sleep apnea.

Each practice must study and note the changes to the most commonly used codes, as well as assess how they will effect billing. Billing managers must also self-educate to verify that they are billing operations correctly due to the large number of regular modifications.

The problem of billing looms huge. We’ve just touched on a few so far. There are also some difficult obstacles to overcome:

Time Constraints: A busy practice with minimal administrative support might be problematic, especially when billing is done manually. The practice will benefit from automation, and services such as electronic attachments can speed up claim adjudication without the need for extra support workers.
Detailed Claims Processing Criteria: Insurance companies and government organizations have strict processing guidelines that must be followed. Failure to comply might result in claims being rejected, among other consequences. The billing cycle of a practice can be improved by managing processing guidelines.
Lack of Supporting Documentation: Rejected claims will almost certainly necessitate supporting documentation. There’s no point in printing and shipping materials to the payer if this is the case. Automate this with a secure electronic claim attachment solution, as previously mentioned. Payers can retrieve documents supplied online with a tracked delivery number while they work to process the claim. Faster reimbursement and fewer problems result from less paperwork and fewer phone calls trying to hunt down claims.

There will always be billing issues, but many of them can be overcome. Because so much is out of your control, you’ll need to be diligent in dealing with billing issues relating to payer processes. However, by integrating technology and automation-based systems, you can fix flaws in your administrative operations.

Stay informed about code changes, as Duncan suggests. Duncan’s free webinar “The 2019 Coding Update,” sponsored by NEA Powered by Vyne, is available here if you need more information on the coding changes and improvements. The session covers coding 15 new additions, five new modifications, and four new deletions that took effect on January 1, 2019. You can also sign up for Duncan’s next 2020 Dental Coding Update webinar, which will take place on January 7, 2020.

Mr. Patrick is the president of Vyne’s dental division. He has worked in the dental profession for over 20 years and has written numerous articles for most of the industry’s prominent periodicals on a variety of current practice management issues.

Which factors help ensure successful accurate dental claims processing?

These pointers came from conversations with insurance company dentists, dental consultants, and clinics that have effectively followed process to increase the success of their dental insurance claims.

X-rays

You must include a stamped self-addressed envelope if you want your x-rays returned.
Periodontal surgery is a technique that is used to treat gum disease (gingival flap procedure, osseous surgery, crown lengthening, bone grafts)
For restorative, endodontic, periodontal, and surgical procedures, send pre-op.
Send a post-op x-ray to document root canal treatment for build-ups, posts, and where periapical pathology was seen in the pre-op x-ray.
Send a post-op x-ray demonstrating successful results for teeth with a doubtful prognosis.
Send a post-op x-ray documenting that the post is truly a custom post and not a prefabricated post for bespoke indirectly produced posts.
Pre-op refers to the time preceding any operating surgery, like as crown prep, filling removal, endo access, and so on.
Take a look at the x-rays your office sends out; you might be surprised at the (lack of) quality!
Ensure that the contrast is sufficient and that the intricacies of the tooth, restorations, bone, and disease are visible.
For many disorders, periapicals and bitewings are usually more diagnostic than a panoramic x-ray.
A panoramic x-ray may reveal a complete tooth that needs to be pulled that isn’t seen with periapicals.
We take multiple x-rays because different x-rays provide different information. As a result, incorporate them.
Don’t just send one periapical when filing for a perio procedure. If bitewings are available, please send them as well. Send a full mouth series if one is available. If a pano is available, please send it as well.
A bitewing may only show the crown of a tooth and not the root. The periapical displays the entire root but excludes the crown. If that’s the case, send them both.
Don’t send photographs that are excessively large; bigger isn’t always better. Although having one x-ray occupy a whole page may appear to be a smart idea, it is actually overkill and can slow down processing. Large printed x-rays are frequently blurry and difficult to view.
Annotations should not, however, be written in such a way that they obscure other vital information.

Periodontal Chart

Periodontal procedures (gingival flap procedure, osseous surgery, crown lengthening, bone grafts, gingival grafts)
At a minimum, the perio chart should include pocket depth measurements for all teeth in the operation region, as well as missing teeth.
Gingival margin level, furcation involvement, mobility, bleeding spots, and associated gingiva width are also beneficial.
Make sure your handwriting is neat. Make sure the numbers are legible to a third party.
Include your diagnosis on the perio chart if you’re treating periodontal disease. Remember that scaling and root planing is a disease therapy that requires a verified diagnosis of the ailment.

Clinical Photographs

Send a photograph if the x-ray does not adequately document the tooth condition. It’s fairly uncommon for an initial claim to be refused but later approved after a photo is submitted since the necessity is seen on the photo but not on the x-ray.
Make sure the photo clearly depicts the tooth or condition in question, as well as any supporting material for the operation you’re submitting.
Photos of crowns or veneers on anterior teeth are useful in demonstrating that the operation is not just aesthetic.
When it comes to periodontal grafting, pictures can indicate recession and a lack of connected gingiva that an x-ray cannot.
Large buccolingual widths of existing fillings can be seen in photos that aren’t visible on x-ray.

Narratives

When you write “open margin,” you mean “open margin.” It does not imply that degradation occurs on a regular basis. If there is any degradation, include it as well.
“Open contact” just means “open contact,” but it doesn’t specify what, if any, problems that open contact is causing.
If your narrative is too long to fit on the claim form, write it on a separate page and note it in the narrative area of the claim.
“Scaling and root planing are required in the treatment of periodontal disease.”
“Periodontal treatment is required to improve the general health of the mouth and the dental environment.”
If you’re going to use acronyms, make sure they’re well-known and understood.
To make the story more readable, use proper grammar, punctuation, and spelling.
It will have no impact on the speed with which your claim is processed or approved.
It’s unnecessary to remind the insurance firm of the rules, regulations, standards, and laws that apply to them. They are well aware of this; in fact, they are probably far more aware than the claimant.
Citing legal examples has no beneficial impact on a claim and, in fact, can undermine credibility because many of the instances cited are not applicable to dental insurance claims.
“Please be advised that if the claim is not paid within 30 days of its creation, the insurance commissioner will be alerted.”
“We will file an official complaint with the insurance commissioner unless this claim is settled or denied within 30 days.”
The more personalized the narratives are for this patient, the more credibility and effect they will have.
It’s fine to use a pre-made template or form as long as it’s filled out in a fashion that’s clearly particular to the submitted claim and customized for each treatment or tooth.
Including every possible conclusion that could lead to a surgery being covered can jeopardize the credibility of the procedure.
Include anything that has been documented in the patient’s records…but leave out anything that has not been documented in the patient’s records.

Claim Form

Make a careful note of whether a crown, bridge, or other fixed or removable prosthesis is a replacement or not.
Note when the existing one was placed if it is not an original placement (prior placement).
Crowns, bridges, inlays, onlays, veneers, and detachable appliances are all examples of prior placement. It isn’t referring to the placement of fillings beforehand.
In the Billing Dentist area, enter the correct entity, and in the Treating Dentist part, enter the correct dentist.
In the Provider Specialty Code area, specialists can indicate their specialty.
The Area of Oral Cavity is required by some standards, whereas the Tooth Number is required by others. This is determined by the CDT code and the insurance company’s policies.
If a patient discount is granted, it must be clearly recorded on the claim, either as a distinct line item or in the Remarks, if it is not already calculated into the fee on the claim form. Otherwise, a bogus claim will be submitted.

Miscellaneous Tips

If you plan to do more scaling/root planing or osseous surgery in other quadrants later but won’t be submitting for all of them on the claim, attach x-rays and a perio chart for all four quadrants regardless. Some consultants will automatically pre-process all four quads and save them in the computer if you do this, saving you time on future submissions.
Make sure to use the proper wording. If it’s a “diagnostic,” for example, don’t write “prognosis.” If a restoration is genuinely a “inlay,” don’t call it a “onlay.”
Get to know the CDT codes and descriptors inside and out. Reread them on a regular basis to refresh your memory on the descriptors for codes you don’t use often. Ensure that everyone in the office, including the doctors, is familiar with them.
If you get a request for information after filing a claim, send the information requested…plus more. This indicates that rather than being processed by a computer, the claim is being evaluated by a human. Make sure to include material that clearly documents what you did, as well as the necessity for doing it. Explain it in a narrative and/or give images if it isn’t immediately apparent on the x-ray.
Requesting a phone contact in the goal of increasing the possibility of payment should only be done if you have information that has to be conveyed. Insurance companies are not more inclined to pay a claim simply to avoid having to call them. Any request for a phone call will cause a delay in the claim’s processing.
Exam findings and any specific exam actions should be documented (such as how a cracked tooth was diagnosed, pulp tests and specific results, Diagnodent use and readings).
Any x-rays obtained should be documented, as well as the fact that they were read and which dentist evaluated them.
Document each tooth’s decay discoveries, including how it was discovered and the surfaces where it was discovered.

Appeals

Send supplementary paperwork if you’re resubmitting a claim on appeal. Don’t simply resubmit the claim in the hopes of a different review the next time.
If a claim is being resubmitted with updated information, label it “Corrected Claim” and emphasize the updated information.

Things To Remember

Payment for a procedure may be denied, but it does not always mean you cannot have it done. It simply indicates that the benefit isn’t included in the insurance plan that the patient’s employer purchased on their behalf.
Send in high-quality x-rays. Nobody at the insurance company can notice the condition in question if you can’t see it on the supplied x-ray.
Do not defraud an insurance company. In terms of legal fees, refunds, and dental board fines, this can be very costly. Fraud can take many different forms, including:
Using a date of service that is not the same as the day you performed the treatment on the patient.
Submitting a fee that is not the same as the fee you want to charge the patient (unless you have a contract with the insurance company).
Using a CDT procedure code that isn’t the most correct for the process that was actually performed.
Providing fillings for more dental surfaces than were actually filled.
Submitting a perio chart that depicts the patient’s perio pockets to be deeper than they are.
Insurance firms can normally obtain copies of records in order to investigate the veracity of any claim that has been filed (this concept is true for any insurance claim, not just dental insurance claims). Keep in mind the legal experts’ philosophy…

How long does dental insurance take to pay out?

The time it takes for a dental insurance company to process a claim varies. At least 38 states have passed legislation requiring dental insurance companies to pay claims promptly (ranging generally from 15 to 60 days). Contact your state’s insurance commissioner if you want to submit a complaint about a late payment. They want to know if your insurance carrier fails to pay within the time limit set by state law.

What is a deductible for dental insurance?

Dental insurance can help you save money on dental care that you would otherwise have to pay out of pocket. The majority of dental plans work like this:

You have to pay a fee. This is usually a monthly payment for getting dental insurance. Dental coverage provided by your employer may be withheld from your wages. If you purchase a plan on your own, you pay the monthly premium to the insurer directly.
It’s possible that there will be a waiting period. This means you may have to wait up to 6 months before you’re covered for dental care other than routine oral checkups.
You may require the services of a primary dentist. Some dental insurance plans may require you to select a primary care dentist. This is the dentist you’ll see if you have any issues, and they’ll coordinate any specialty dental care you might require. Learn about the differences between dental HMO and PPO insurance.
Is it better to be in-network or out-of-network? You may or may not be compelled to see dentists in the plan’s network, depending on the plan you choose.
The importance of frequency and restrictions cannot be overstated. These dental coverage words explain what you’re covered for and what you’re not. Once every six months, for example, you can get a free dental exam and cleaning. Furthermore, you may only be covered for a restricted range of dental services and treatments, ranging from basic to major.
One or more deductibles may be included in your dental insurance policy. A deductible is the amount you must pay out of pocket for dental care before your insurance plan begins to share the costs.
Other expenses related to your plan. Once you’ve met your dental deductible, you and your plan will start splitting the cost of your dental care. This is referred to as coinsurance. There may be an annual maximum on your dental insurance. This is the maximum amount of money your plan will pay for dental care in a given plan year. After that, you will be responsible for any further care expenditures. Some plans also require you to pay a small fee when you go to the dentist. This is referred to as a copay.
Preventive dental care is frequently provided at no cost. This means you’ll get an oral exam and some types of standard X-rays every six months. As part of their preventive care, children may receive more routine attention. When you choose a plan with no cost preventative care, this is included in your dental insurance at no cost to you.
Preventive, restorative, orthodontic, and other types of dental care are all covered under dental insurance. You may have more or less coverage for specific types of dental care depending on the type of dental plan you purchase. This is why it’s critical to prepare ahead for the dental care that you and your family may require. If you just expect to need preventative dental treatment, for example, a basic dental plan that only covers preventive dental care may be sufficient. A dental plan that covers more specialized dental care and procedures, such as crowns, root canals, bridges, implants, and so on, may be a better fit for you if you anticipate needing crowns, root canals, bridges, implants, and so on. Full coverage dental insurance may have higher monthly premiums, but it will help you keep your out-of-pocket costs for expensive dental operations under control.

What is CPT in dentistry?

When billing complex oral surgery to PrimeWest Health, dentists and board eligible and board certified oral and maxillofacial surgeons must use the physician’s CPT procedure codes. The provider must be separately enrolled with PrimeWest Health in order to obtain compensation for CPT procedure codes.

Dentists who use CPT procedure codes and coding must choose the code that most accurately identifies the operation or service done. Any additional procedures or relevant special services must be included as well. List any modifying or extenuating factors as needed.

Any service or procedure must be properly documented in the medical record of the member. On the 837P, a dentist’s medical services must be billed using current CPT procedure codes.

What is the best thing about dental billing?

It should come as no surprise that the primary motivation for adding medical billing to your dental business is to generate revenue. Cross-billing practices have produced an average of 30-40% more money than traditional dental practices.

One of our clients is Doctor J from Glendale, California. He was able to get a reimbursement of roughly $3,700 from a medical insurance carrier for a bone grafting treatment thanks to the medical billing process and the assistance of New Era Consulting. Doctor J would likely only collect roughly $500 for the operation if he solely billed the services as dentistry.