Denied Insurance Claims for Oral Surgery? Uncover Common Reasons

by | Published on Oct 23, 2023 | Dental Insurance Verification

Denied Insurance Claims
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Dealing with insurance companies and facing claim denials are undeniably a few of the most exasperating facets of the dental field. Managing dental insurance billing becomes quite challenging and tedious, particularly when claims are either delayed or outright denied. Claims often face denial due to minor, easily overlooked errors. Many dental practices now rely on dental billing services to streamline their financial processes and ensure accurate reimbursement from insurance companies.

It’s essential to understand why your claim was denied so you can take appropriate action to address the issue. Here are common explanations for denied insurance claims for oral surgery:

Common Reasons for Denied Oral Insurance Claims

Inaccurate dental codes

To ensure the accurate processing of a dental claim, it’s crucial to include the appropriate, up-to-date code set that accurately identifies the diagnosis, services provided, and procedures provided. These codes can be either CDT codes or ICD-10-CM diagnosis codes.

Errors in coding are perhaps the most common mistakes because codes can be challenging to stay current with, given that they undergo annual updates and revisions.

Obsolete Insurance Claim Documents

Dental insurance providers periodically revise their claim forms and the required information. It’s crucial to stay informed about these updates to avoid submitting outdated claim forms, which can result in claim denials.

Insufficient or Inaccurate Details Provided in the Dental Insurance Claim

It’s quite common to make typographical errors such as misspelling a name, entering the wrong insurance number, or encountering input errors when handling dental insurance claims. Sometimes, these errors can occur not due to input mistakes but because patients have updated their information without informing dentist.

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Insurance Verification

Performing insurance verification is a pivotal measure to prevent insurance claim denials. Prior to a patient’s visit, reviewing their benefits ensures that their information is current, their coverage is active, and provides insights into the extent of their insurance coverage for specific procedures. Leveraging expert insurance verification, enhanced by technology-assisted methods, can efficiently streamline this crucial process for the practice. Dental eligibility verification is an essential step to ensure that patients receive the appropriate coverage for their dental procedures.

Illegible Data and Documents

As insurance companies and dental offices shift towards digital records, a prevalent issue that emerges is the presence of indecipherable information or files. When the text is too faint, smudged, or outright illegible, it can lead to delays in processing insurance claims.

To prevent this issue, consider including high-quality images and x-rays along with your insurance claim submission. Utilizing an intraoral camera can be particularly advantageous in this regard. This specialized camera is capable of generating color photographs that faithfully depict what can be observed by the human eye. Consequently, it effectively communicates the patient’s oral condition, a vital component for any insurance claim.

Provision Regarding Absent Teeth

In this scenario, a patient visits the dental practice with a missing tooth and asserts that they possess dental insurance coverage. They proceed to submit the relevant insurance claim, but the insurance provider rejects the claim, citing that “the extraction of the missing tooth occurred before the patient’s dental coverage took effect, and therefore, its replacement is not covered under the policy.”

The most effective approach to prevent this problem is to thoroughly understand the patient’s insurance benefits before initiating any actions, particularly for complex procedures. This underscores the importance of conducting comprehensive insurance verification.

Contract-based Rejections: Clinical and Restrictive

Contractual Clinical Denials arise when specific services are excluded from coverage within a contract, often including cosmetic procedures. On the other hand, Contractual Limitation Denials involve delays or denials due to contractual limitations related to factors such as age, frequency (the time interval required before performing additional procedures on the same tooth), or waiting periods.

It is essential to confirm the patient’s insurance coverage before proceeding with any medical procedure, ensuring that their benefits are currently active and comprehending the scope of coverage. For instance, if a patient requests a teeth-whitening procedure, it is crucial to determine whether their insurance plan includes coverage for cosmetic treatments like this. Additionally, a thorough understanding of the insurance plan’s regulations concerning treatment frequency and waiting periods is necessary.

The responsibility for comprehending the intricacies of a patient’s insurance benefits primarily rests with the healthcare practice, as patients often have limited knowledge of the specifics of their own coverage.

Lack of Clarifications Provided on the Claim Form

If you cannot provide a clear and documented rationale for the necessity of a procedure, the likelihood of the insurance company granting approval for the claim is minimal. It is imperative to consistently offer a detailed and patient-specific explanation for the rationale behind a procedure.

It’s observed that some offices face claim denials or potential legal issues when they employ generic narratives or predefined explanations on their claim forms. This refers to using pre-written or default justifications for the necessity of treatment. It’s essential to steer clear of this practice and avoid omitting explanations entirely.

Absence of Student Verification

Insufficiently documenting a student’s status frequently results in denied or delayed claims. If the patient’s student status has the potential to impact their insurance coverage, it’s crucial to thoroughly examine the patient’s benefit plan in advance to gain a comprehensive understanding before proceeding with the procedure.

In conclusion, understanding the common reasons behind denied insurance claims for oral surgery is pivotal in navigating the complex landscape of dental insurance. Dental billing services can play a big role in resolving the issues. By addressing issues such as incomplete documentation, inaccurate coding, lack of medical necessity justification, contractual limitations, and patient eligibility, dental practices can proactively work to reduce claim denials and ensure that patients receive the coverage they deserve. Through meticulous attention to these factors, both dental professionals and patients can strive for smoother claim processing, improved transparency, and ultimately, enhanced access to essential oral surgery procedures.

Amber Darst

Amber Darst is our Solutions Manager in the Healthcare Division, Practice and RCM. With a rich background in dental services, her expertise ranges from insurance coordination to office management.

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