How to Ensure Efficient Dental Insurance Verification and Claim Submission

by | Published on Apr 18, 2016 | Insurance Verification and Authorizations

Dental Insurance Verification
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Dental insurance verification is the important first step in your dental medical billing cycle to ensure that the dental services you offer are paid. Almost 75% of dental insurance claims have issues with reimbursement due to insurance eligibility being incorrectly assessed. Dental facilities need to get the insurance verification process accurate.

Comprehensive Verification and Accurate Claim Submission

A few measures could help ensure you minimize claim denials. One of the primary tips is to take all the required effort to correctly send the claim the very first time. While this instruction may seem pretty obvious, it is often the case that claims are incomplete. Do not wait for information to be requested before it is sent, which often seems to be happening.  That’s why you need to have a proper verification system in place:

  • Sometimes outsourcing insurance verification could be a good thing, since the outsourcing provider would not be relying on the information provided by the patient alone. Whatever be the method you choose to verify, ensure that the claim is sent to the right place.
  • Make sure that you send x-rays connected with all the implants, crowns, pre-procedure and post-procedure root canals, root planing and scaling. For the SRP (Scaling and Root Planing) procedure, a perio chart is required. For any major treatment, the submitted information should include narratives in the clinical notes so that it can be easily accessed. Only 150 character spaces can get electronically submitted in the Remarks for Unusual Services section.
  • In the case of crowns, it must be documented whether the procedure involves an initial crown or a replacement crown. With a replacement crown you also need to mention the exact date when the initial placement took place, without making it up or coming up with a wild guess. This is tough if the initial procedure did not occur at your facility. You need the support of your patient here. Secure the support by explaining to the patient that they would not receive insurance coverage on the crown unless the date of the initial crown is provided.
  • It is also important to remember that some insurance companies would only pay for the crown procedure after the seating of the permanent crown. So you must keep track of the stages so that you can submit the updated information as soon as the permanent seating is done.
  • You must also ensure that outstanding claims are tracked on a week-by-week basis. You know that clearing houses usually provide you with a status report after claim submission. Make sure that you study these reports each day so you can get insights on the claim status and the reason why the claim was not processed satisfactorily. Checking these out is better than waiting for the EOB (explanation of benefits) to arrive, by which time you would already be 30 days into the claim. Also keep checking the insurance websites as they provide a good deal of information on tracking outstanding claims.
  • Strangely, statistics state that 85% of denied procedures do not get appealed. This is a big mistake, especially considering that 75% of the appealed procedures are reprocessed with payment. If you feel that a denied procedure must be paid you must send it back to be reprocessed, and this also applies for crown buildups forming part of crown prep. Make sure you mention the reason for appeal in a detailed manner.

Information Required for Successful Verification

For all these steps to be successful, it begins with comprehensive insurance verification. A dental facility needs to have comprehensive information on various aspects of insurance eligibility to ensure that the patient has coverage for the procedure that is to be performed. This must include information such as:

  • The dates for which the coverage is effective
  • The codes specific to the procedure to be performed
  • The waiting period which is sometimes required for certain procedures to ensure they are covered
  • The type of plan and the fee schedules
  • Maximums and deductibles
  • Required documentation
  • Information regarding claim submission such as phone number, address, payer ID, and fax number
  • Coverage percentage by category
  • Coverage for tooth implant
  • Coverage for tooth grafting
  • Coverage for crowns, cleanings and build-ups
  • Frequencies for panoramic and full mouth x-rays
  • Missing tooth clause
  • Last date of service

With these bits of data in place, you can also get accurate estimates created for your patients and secure their trust.

Outsourcing dental insurance verification will bring in experienced professionals to handle the various aspects of verification. It would also give you access to smart digital tools that can speed up and improve your verification process – tools that can ensure quick and real-time eligibility verification, improved patient communications, and increased case acceptance.

Julie Clements

Julie Clements, OSI’s Vice President of Operations, brings a diverse background in healthcare staffing and a robust six-year tenure as the Director of Sales and Marketing at a prestigious 4-star resort.

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