Insurance denials can significantly impact your dental practice’s revenue cycle. Efficient billing plays a crucial role ensuring that you receive proper reimbursement for services rendered. One of the most common causes of billing issues and claim denials is failure to verify patient eligibility before the date of service. Dental practices must conduct thorough insurance verification to check if services are covered before providing them. If insurance is not properly checked before rendering services, several billing problems can arise that lead to revenue loss, claim denials, delayed payments, and patient dissatisfaction. Proactive insurance checks prevent billing issues related to the patient’s benefits and coverage limitations.
This post explores common dental billing issues that arise from inadequate insurance coverage verification and how accurate insurance checks prevent them.
Common Billing Problems Caused by Failure to Verify Dental Insurance
Billing issues due to insufficient patient coverage denials occur when the payer determines that the patient did not have adequate insurance coverage for the services rendered.
Let’s dive into the reasons why these denials happen:
Claim Denials Due to Inactive Coverage
If the patient’s insurance coverage had expired or was no longer valid on the date of service, claims submitted will be denied outright. For e.g., the American Dental Association (ADA) points out that an employer may not have sent timely notification to the patient’s plan about termination of the patient’s employment and/or corresponding benefits.
If services are provided without confirming that coverage is active during the visit leads to lost revenue–unless the patient pays out-of-pocket.
Non-Covered Services Rendered
Specific treatments or procedures such as elective procedures and certain diagnostics may not be covered under the patient’s plan. For example, dental plans generally exclude cosmetic procedures like teeth whitening and some elective treatments that are not medically necessary. Not all plans cover dental implants, and the coverage may vary depending on the specific plan.
If you do not check insurance and provide services not covered under the patient’s plan, it will result in denials or reduced payments.
Errors in Demographic and Insurance Data
Even small mistakes in a patient’s details (wrong policy number, incorrect name spelling, incorrect date of birth) can lead to major billing issues, claim rejections, or delays in reimbursement. If incorrect information is submitted with proper insurance checks, the payer may put the claim on hold for clarification or request additional documentation.
This resulted in delays for reworking claims and increased administrative workload.
Out-of-Network Provider Issues
If the provider is not in the patient’s network, the insurance may not pay—or cover only a portion of care. An out-of-network dentist might charge the full amount for services, and the patient might be responsible for the difference between what their insurance pays and what the dentist charges
If out-of-network providers issues are not verified, it leads to unexpected higher costs and potential reluctance to pay.
Missing Prior Authorizations
Some services require pre-authorization. But insurance policies often change at the start of a new plan year, making it challenging for dentists to predict how procedures will be reimbursed. Even when a treatment plan has been pre-authorized or pre-approved, claims may still be denied after the procedure is performed. Common denial reasons include loss of patient eligibility, used annual maximums, or time limitations that have been exceeded.
Omitting insurance checks can result in rendering services without pre-authorization. Claims can be denied even if medically necessary.
Coordination of Benefits (COB) Problems
A patient can have dental coverage from more than one source (e.g., their own employer and their spouse’s employer). When both plans have COB provisions, the plan in which the patient is enrolled as an employee or as the main policyholder is primary. The plan in which the patient is enrolled as a dependent would be secondary. Verifying insurance coverage can prevent billing issues and claim denials or delays due to COB problems.
Without verifying the patient’s coverage, their multiple insurances, and which one is primary, the claim might be submitted to the wrong payer.
Exceeding Coverage Limits
If benefit caps are not checked, services beyond those limits will not be paid.
The annual maximum or “cap’ is the maximum amount the dental insurance will pay toward the cost of covered procedure in a benefit plan year. Once the annual maximum is reached, patients are fully responsible for any further dental services received until the next plan year. Orthodontic benefits typically come with lifetime maximums, meaning the insurance plan will pay up to a fixed amount for orthodontic treatment—such as braces or aligners—over the course of a patient’s life, not per year. Once this limit is reached, no additional orthodontic expenses will be covered, even if the patient switches to a new plan with the same insurer.
Checking insurance and understanding these caps is essential to avoid unexpected out-of-pocket costs during treatment. Billing for services exceeding maximum allowable benefits leads to denials.
Incorrect Patient Responsibility Estimates
Verifying insurance coverage proactively helps patients understand their financial obligations, allowing them to make informed decisions about treatment plans. Without insurance verification, patients may be given inaccurate estimates of deductibles, copays, or coinsurance. This can lead to financial misunderstandings, potential disputes with patients, and delayed collections.
Increased Administrative Burden
Failing to verify a patient’s insurance coverage upfront can significantly increase the administrative workload for your dental office. When claims are denied or delayed due to eligibility issues, staff will spend more time troubleshooting problems, reworking denials, contacting patients, and resubmitting claims–problems that could have been prevented with a quick insurance check.
More appeals, documentation, and rework results in higher operational costs, reduced productivity, payment delays, and less time to focus on revenue generating tasks.
Poor Patient Experience and Credibility Issues
Billing surprises due to lack of insurance checks can upset patients and harm trust. This leads to negative reviews and loss of repeat business.
How Patient Eligibility Verification improves Dental Billing Accuracy
By addressing insurance coverage problems with proactive checks, providers can significantly reduce claim denials and improve overall financial performance. Here’s how robust insurance verification prevents billing issues:
- Prevents Claim Denials: Verifying eligibility ensures the patient has active coverage, reducing denials due to ineligible or inactive policies.
- Confirms Covered Services: Helps identify which dental procedures are covered under the patient’s plan, avoiding billing for non-covered services.
- Clarifies Benefit Limits: Detects annual maximums, frequency limitations, and waiting periods upfront, improving claim accuracy.
- Ensures Proper Coordination of Benefits (COB): Verifies if the patient has secondary insurance and which plan is primary, minimizing COB-related denials.
- Ensures Accurate Patient Estimates: Allows front desk staff to provide more precise out-of-pocket cost estimates, improving transparency and collections.
- Avoids Prior Authorization Errors: Confirms if specific procedures require pre-authorization, helping avoid denials for missing approvals.
- Reduces Rework and Resubmissions: Fewer denials mean fewer claim corrections, saving staff time and boosting billing efficiency.
- Improves Cash Flow: Accurate claims processed on the first submission lead to faster payments and improved revenue cycle performance.
- Enhances Patient Satisfaction: Fewer billing surprises and clearer financial communication result in a better patient experience.
Optimize your dental billing process with comprehensive insurance eligibility verification!
Why Outsource Dental Eligibility Checks
The complexity of insurance policies and the ever-changing landscape of healthcare coverage can pose challenges to the dental insurance verification process. This makes it difficult to determine patient coverage accurately, which can lead to errors and claim denials.
Now suppose you have experts to handle insurance checks? Experts can help you develop a comprehensive checklist for verifying demographic and insurance information for new and returning patients. They are knowledgeable about payer policies and can ensure real-time verification to ensure accurate information. By using automated tools and helping you maintain open communication with patients and payers, their proactive dental insurance verification checks can prevent billing mistakes, reduce claim denials and help your practice achieve financial success.
Reduce denials and boost collections with expert dental insurance verification services.
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