Avoiding Claim Delays and Denials

Dental claim delays and denials always top the list of practice complaints. Delays and denials can hurt both patients and practices. It is estimated that 163 million Americans are covered by a dental benefit plan. In fact, a recent ADA survey indicated that as many as 65% of patients depend on their insurance for at least a portion of their dental expenses. Even dentists who do not file claims directly for their patients know that individuals with insurance rely on that insurance to help them pay for the treatment they need and want.
Do carriers purposely delay claims? What are common claim issues that delay prompt payment? What information is necessary to process claims and avoid denials? How can offices support patients with in-surance without becoming slaves to their benefit plans?

DO CARRIERS PURPOSELY DELAY CLAIMS?

Illustration by Brian Green

It is unlikely that insurers intentionally delay claims to make more money. In fact, many plans are self-funded by employers, meaning that the insurers are functioning as Administrative Services Only (ASO) facilitators. In these cases, the plan is not liable for payment of patient claims. The employer is. ASO facilitators are typically paid per transaction, which eliminates any monetary advantage for the plan to hang on to claims.
Benefit companies that do assume payment liability (non-ASO) face other concerns. Many states have legislation that mandates prompt payment from standard indemnity benefit plans. Plan purchasers also typically include contract provisions requiring reasonable claim processing turn-around times. Delayed claims can mean delayed premiums or even monetary penalties to the benefit company. In addition, if the employees who are enrolled in the plan are unhappy and complain to their Human Resource Coordinators in large enough numbers, the plan may lose their contract.

WHAT ARE COMMON CLAIM ISSUES THAT DELAY PROMPT PAYMENT?

Claims may be delayed for a variety of reasons. The prime reason? Insufficient or unclear information on the claim form. Therefore, the easiest way to reduce delays is for the practice to be sure that all information needed to pay a claim is included on the form the first time. According to the National Association of Dental Plans, payers process more than 250 million claims annually. Seventy percent are analyzed using computerized “decision logic” based on the contract provisions of the patient’s policy. No human beings required. Surprisingly, this computerized processing can be accomplished on either paper or electronic claims. (Paper claims simply have to be scanned or keyed in first by plan operators. A human being is required). Paper claims that are handwritten or unclear are held up because their information cannot be readily transferred to the computerized format. Requests for clarified information then must be sent out to the dentist, and the claim is delayed.
Conversely, electronic claims typically go through a clearing house first. The clearing house software “looks” for unclear, incorrect, or missing information prior to the claim being sent on to the benefit company. The clearing house can let the practice know about any issues that need to be addressed before the benefit company receives the claim. This greatly cuts down on claim delays. Although e-claims are touted as being paid more quickly than paper claims, which they are, the turn-around time is typically not as fast as many companies advertise. The main electronic format advantage is a reduction in possible claim errors, meaning a reduction in payment delays. According to the ADA and the National Association of Dental Plans in their joint ADA News series, “Top 10 Insurance Concerns,” offices make several common claim mistakes that cause delays:

  • Not using the current version of the ADA Claim form, which now is J400 (a copyrighted term) 2006, or not using the plan-specific form a contract requires.
  • Neglecting to complete all of the dentist’s information including name, address, and tax identification number (TIN). (Note: A dentist’s National Provider Identifier [NPI] number was originally going to be required by May 23, 2007. That deadline has been extended until May 23, 2008. After that date, a treating dentist will need a NPI 1, which will be entered in section No. 54 of the ADA Claim form. A billing entity or corporation will need a NPI 2, which will be entered in section No. 49. An incorporated dentist will need both a NPI 1 and a NPI 2 number.)
  • Neglecting to include all pertinent information about the patient and the in-sured person on the claim.
  • Not using current  dental terminology (CDT) codes, which are now those in effect for 2007 to 2008.
  • Sending claim forms to the wrong payer. (This apparently happens frequently enough to have made it to the “top 10.” An office mistakenly includes other company claim forms with correct company claim forms). These incorrectly received forms have to be returned to the dental office.
  • Omitting the treatment date of service.
  • Using the “remarks” section No. 35 of the ADA claim form for information not related to a treatment-specific narrative. Narra-tives should be brief and to the point and limited to details concerning the treatment being listed on the claim form. Claims containing narratives cannot be flashed through the computerized formats and must be evaluated by a human being. This can be a positive when the explanation results in the claim being paid. However, if offices use the re-marks section for other comments, such as “payment expected in 7 days,” the claim is delayed needlessly.
  • Using an outdated benefit plan name or clearing house code on an e-claim.
  • Not including periodontal charting and/or radiographs when required.
  • Neglecting to include the date of previous placement for crowns, bridges,
    or removable prostheses. Most contracts will only pay for these items every 5 to 10 years, depending on the plan.

WHAT INFORMATION IS NECESSARY TO PROCESS CLAIMS AND AVOID DENIALS?

Don’t neglect to include the simple facts of the case, such as tooth numbers, quadrants, missing teeth, or dates of prior placement of crowns and bridges. In addition, do not leave blank the section titled “Other Coverage.” If there is no other benefit coverage, this needs to be noted. If the section is left blank, a request for more information is likely. Dentists and staff need to be sure that information sent on or attached to a claim actually demonstrates and supports a reason for the requested service. Because benefit plans typically contain contract language that excludes certain treatments or limits certain procedures, any details that might include a procedure are important. Narratives, periodontal charting, diagnostic radiographs, photographs, and any other documentation supporting the treatment can be helpful. These items need to be labeled clearly, including the patient’s name, the dentist’s name, the date of service and, importantly, the right and left views of radiographs. Narratives and/or attachments need to be adequate enough for a reviewer to be able to understand why a service is being recommended and exactly what that service is. Offices need to include as much information as possible the first time a claim is submitted, rather than waiting for a delay or denial and a subsequent request for more details. Put yourself in the reviewers’ place and imagine what you might need to see if you did not have the patient in front of you.

DENTAL NECESSITY?

What about a claim for treatment that may not be included in a plan, but is not specifically excluded? In these cases, payment may be allowed according to a request based on “dental necessity.” Dental necessity provisions are a part of some dental contracts, but not others. This is unlike provisions for “medical necessity” which are typically included in all medical plans. If a contract has a “dental necessity” clause, a dentist who functions as a consultant for the benefit plan may be called on to review a previously denied claim to see if documentation supports payment. According to the National As-sociation of Dental Plans, the 3 most common reasons for denying a dental necessity claim are for extraction of asymptomatic third molars, os-seous surgery where documented bone loss is not seen, and crown buildups. Special care should be taken when filing claims for these services to include evidence supporting the treatment. For example, crown buildups may be paid when over 50% of the anatomical crown of the tooth is gone or when the tooth has had previous endodontic treatment. A narrative, photos, and radiographs backing this up are essential.
Detailed documentation is also particularly important in the area of periodontal treatment. For example, many contracts specify that for D4341 Periodontal Scaling and Root Plan-ing to be a benefit, a patient must be a Case Type III or more, with periodontal charting depths of 5 mm or deeper, and documentation of recession, bleeding, mobility, and furcations. Osseous surgery requests require similar details and documented bone loss. (Note: In 1999 the American Academy of Periodontol-ogy published a new disease classification system developed as the result of an international workshop for the study and clinical management of periodontal disease and conditions. The new system is called, “Classification of Periodontal Di-seases and Conditions” and may be seen in the Annals of Periodontology, Volume 4, December 1999, or in my resource manual, The Dental In-surance Coding Handbook 2005-2008. Despite the new system, most insurance plans are still recognizing the Case Type designations.)

HOW CAN OFFICES SUPPORT PATIENTS WITH INSURANCE, WITHOUT BECOMING SLAVES TO THEIR BENEFIT PLANS?

We perform what most patients consider to be a valuable service when we help them deal with their insurance. Despite the fact that the benefit plan is “their” responsibility, most patients need help navigating the process. They appreciate receiving assistance, and thus may be more inclined to accept complete treatment. Scheduling a treatment conference in advance of procedures is a plus. Patients need to understand both their treatment and the total costs involved. They need to know that insurance may or may not pay what the benefit plan says it will. If it does not pay, the patient is responsible.
Many dentists are reluctant to present the full cost of care in advance of a patient’s first series of appointments. They fear that if a patient understands their total financial commitment, they may not come back. Even if this were true, how is it better for the office to complete a case on a patient who does not understand his treatment and does not understand what it will cost? These are the patients who file malpractice suits and/or refuse to pay their bills. Offering a written estimate and financial help in the form of insurance claim assistance, accepting credit cards, and no-interest bank financed loans can make a big difference for patients.
To make insurance issues less a case of constantly “putting out fires,” the office might also develop a policy for how claims will be handled. This policy can be explained and presented to patients in a written format during a treatment conference. The policy can outline office responsibilities and patient responsibilities in regards to insurance. (Each dentist needs to decide what he/she is willing to do.) An example:

1. Office Responsibilities

  • Complete insurance claims and submit them to your carrier for you within 24 hours of treatment.
  • Use current ADA codes for correct reporting of procedures.
  • Accept direct payment from your carrier and keep track of balances.
  • If necessary, refile your insurance a second time within a 60-day period.

2. Patient Responsibilities

  • To pay fees not covered by my plan at the time of treatment.
  • To provide the office with necessary information concerning my insurance coverage to allow correct filing of claims.
  • To understand that my plan is a contract between myself, my employer, and my insurance carrier. I know that the dentist does not have the power to make my plan pay.
  • To pay any account balance in full if not paid by insurance after 2 billing attempts.

WHAT ELSE MAY HELP?

Brochures or other office handouts can reinforce the beneficial but limited nature of dental benefits. (Read my brochure, “My Insurance Covers This…Right?,” available at steppingstonestosuccess.com.) If patients trust us they will understand that it is a mistake to let benefits be their only consideration when determining what they want to do about dental conditions. New emphasis on the relationships between oral disease and systemic conditions makes dental treatment even more important.


Ms. Tekavec is the author of the Dental Insurance Coding Handbook-2005-2008. She has appeared at all major United States dental meetings and is a presenter for the ADA Seminar Series. She has been featured in Dentistry Today’s Leaders in Dental Consulting for 9 years. She is the designer of a dental chart that has been endorsed by the Colorado Dental Association, as well as the author of a series of patient brochures explaining various dental procedures. Still practicing as a clinical dental hygienist, she is the president of Stepping Stones to Success. She can be reached at (800) 548-2164 or by visiting her Web site at steppingstonestosuccess.com.

Disclosure: Ms. Tekavec is the author of the book Dental Insurance Coding Handbook-2005-2008 and brochure, “My Insurance Covers This…Right?”, both mentioned in this article.

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