It’s a fact, insurance companies work to deny procedures and release the lowest amount of reimbursement possible, period. It’s the sole reason your dental team even has to appeal claims.
Is it annoying and time consuming? Yes.
Is it difficult? It can be.
But is it necessary? Absolutely.
Among the many downgrades, alternate benefits, and exclusions to your patients’ policies, sometimes procedures are just downright denied that shouldn’t be. You should have read the fine print, right?
This may sound nerdy, but at Dental ClaimSupport, we love the appeals game. Working with hundreds of dentists and thousands of claims, we have had our fair share of matches with insurance companies. The trick is to look at it as a game or challenge and not get discouraged.
The bottom line is that you need to know how to win these battles. As dental professionals, we have a duty to fight for our doctors and their patients to collect as much reimbursement as possible from insurance companies.
By the end of this article you will possess the knowledge needed to eliminate the need for many appeals, yet the skillset to get down and dirty with the insurance companies. It’s a chess match, but two can play this game, and you can win dental insurance appeals.
As you know, an appeal is a request for reconsideration and reprocessing of a claim that has already been processed by the insurance company.
Dental claim appeals are necessary if a claim is denied from insurance that you feel should have paid, or if a plan paid less than what you feel it should have.
A few common reasons you would want to send an appeal are for
Any incorrect denials
The most important thing about appeals is that they are inevitable, yet they are necessary. Insurance companies are the biggest buildings in any city you visit. Why? Because they deny claims!
So you being the smart person you are, know that if a procedure should have been covered by insurance, but wasn’t, you need to figure out how to overturn that decision. Knowing how to win insurance appeals will save your patients money and put insurance dollars in your pocket.
5 tips to win dental insurance appeals
Tip 1: Give the insurance company all the information you have for a specific claim
When trying to avoid the need to make appeals, give the insurance company as much info for a claim as possible. This will cut down on denials.
However, claims may still be denied due to lack of evidence. There are times when an x-ray and narrative aren’t enough. X-rays can’t see what the naked eye can. Use detailed narratives and intraoral photos to give as much evidence as possible as to why the procedure was necessary.
Tip 2: Have a list of appeal information for each insurance company
Every insurance company is a bit different regarding their appeals process. This, of course, is another way to make appeals more difficult and for offices not to follow through with the process.
For example, some insurance companies want a new claim with additional information. Some want the original Explanation of Benefits (EOB) accompanied with additional information. Some want the new claim and/or original EOB sent to a different address than where initial claims are sent.
Some want them sent directly through their web portal. Gathering this information for each insurance company and cataloging it will shorten the time needed to submit each appeal.
Tip 3: Have appeal templates ready for submission
Many of the same procedures are denied or downgraded. Have an appeal template for each type of procedure ready and on deck to save time and be efficient. Switching out a patient’s name and claim number and providing additional information specific to that patient is easy if your template is already in place.
Tip 4: Don't accept "no" for an answer
The majority of offices don’t follow through on claim research and will accept from insurance what they are given. Most of the time, the first appeal will overturn the original decision and benefits or in some cases additional benefits will be paid out.
When working through denials, no pays, and your insurance aging report, if you don’t agree with the decision, appeal it!
Do not let insurance companies dictate your dentistry.
Tip 5: Make sure you have your patients' best interests at heart
For patient retention, professionalism and image, it’s always best to collect as much as possible from insurance and leave as much as possible in your patient’s pocket without hurting your own. Patients recognize when an office or dental billing company is fighting for them and keeping their best interests at heart.
What are some commonly denied procedures & dental claims?
Fixed Partial Denture (bridge) – Some insurance plans downgrade and pay on a removable partial denture- Send in a simple narrative appeal as to why the fixed partial denture was selected over the removable. This will overturn the downgrade.
No pay on buildups – Some insurance plans, such as Cigna, only need a seat date and if a crown is an initial or replacement. Call and give it to them or send in the information with the denied claim number.
No evidence to support the need for crown(s) – Was the majority of the tooth compromised? Recurrent decay under the existing restorations? Fracture lines or cusps? An x-ray isn’t always good enough. Utilize your intraoral photos and detailed narratives to get these denials paid.
Timely filing – Show evidence from your clearinghouse that the claim was submitted. This information can be sent to the insurance company with the denial EOB for reprocessing.
Missing tooth clause – Does not apply if an employer switched from one insurance plan to the other and evidence can be shown that the tooth was extracted while the employee was employed under both plans without any gap in coverage.
How can I avoid sending dental appeals in the first place?
This article has focused on dental appeals, but as a dental biller wouldn’t you rather focus on claims that truly either need additional information or attention? Sending clean claims through your clearinghouse will limit the amount of attention you give to claims that should easily process. Make sure you are using a good clearinghouse that fits the needs of your office.
Also, many dental offices out there don’t have a clear understanding of claims submission and how to properly submit claims. This may or may not be you, but every office needs to ensure it is following necessary steps to send clean claims, which lead to less outstanding claims to work in the future. Time is always money! Being proactive with claim submission will lead to faster revenue, less claim cleanup, and a healthier bottom line.