Kyle L. Summerford
Ever heard of Warren Buffett? He’s the man who made most of his fortune by heavily investing in the insurance industry, and of course you’ve heard of him. His net worth is said to be somewhere in the realm of upwards of one hundred billion. Understanding the business model of insurance companies, Mr. Buffett took a gamble and came out one of the richest men today. You see, insurance companies are in the business of making money—not spending it.
One of the most common ways insurance companies ensure their profits soar is to collect monthly premiums from their members (our patients), then deny as many claims as possible by referring to the literature in the patient’s contract, specifically the exclusions, limitations, and/or frequency provisions. Exercising their right to deny payment of a claim based on this literature will ultimately result in decreased payouts and increased profits.
Now that you have a better understanding of an insurance company business model, you need to think like an insurance company and be sure to dot your Is and cross your Ts before you send out that dental claim for processing. Here are the three most common ways insurance companies can deny dental claims and some ways you can avoid them.
Lack of information from the provider
A large portion of dental claims for basic and major services will be placed on pending status and sent back to the dental office, requiring you to send additional information in order for the claim to be considered for payment. Most of the time the claim is sent back due to a lack of information. Be sure to send a full-mouth series or periodontal charting from the last six months for claims requiring this information, such as periodontal, endodontic, and orthodontic procedures, as well as other basic and major services. In some cases, the insurance company will delay payment by requesting a detailed narrative with a written explanation of necessity. Always make sure to be swift and timely with any requests from the dental insurance company to facilitate claim processing.
Untimely filing
Dental claims should be submitted upon completion of the services provided. Failing to submit the claim on time is an easy reason for the insurance company to deny the dental claim. Most PPO plans require the claim be submitted within one year from the date of service. There are also some local union plans that have even shorter timely filing periods, such as 90 days. If the claim remains unpaid past these deadlines, you will then be at the mercy of the untimely filing rule and can expect to have that claim denied and unpaid should you resubmit. You may be able to request an appeal, but most times this request will be rejected.
Limitations, exclusions, frequencies
All dental plans are not created equal. Most dental plans are based on what the patient’s employer has agreed upon with the dental plan provider. Limitations such as annual or lifetime maximums control how much is paid out on a dental plan policy. Frequencies help to keep the insurance companies’ costs down by ensuring a patient can only be covered for certain procedures a few times a year or every few years. Excluding or down-coding certain procedures occurs all too often and helps to minimize insurance payout.
Don’t expect reimbursement for a dental implant when the patient could’ve had a three-unit bridge instead. Most of the time they will down-code the more expensive procedure to a less costly one and provide an alternate benefit, resulting in lower reimbursement. The list of reasons for not covering procedures due to limitations, exclusions, and frequencies can go on and on, as they usually vary from plan to plan. This is why it is vital to find out what is covered and not covered prior to performing any procedures by obtaining a breakdown of benefits and submitting a predetermination for more costly procedures if necessary.
You see, insurance companies are in the business of making sure their quarterly earnings are soaring. They tend to make decisions based on their own pockets and not based on what’s best for your patients’ health and well-being. That’s why you should make sure everything is in order before submitting a claim.
Editor’s note:An earlier version of this article was published on DentistryIQ in February 2018.
Kyle L. Summerford is a nationally recognized practice management guru, author, and lecturer. As founder and president of Summerford Solutions Inc., he provides powerful information for dental staff members on his website, DDSGuru.com. Kyle also serves as editorial director of Pennwell’s Dental Office Manager Digest e-newsletter. He lectures extensively to dentists and their staff on topics such as insurance coding and billing, and useful practice management tips.
