Secondary Claims, Claim Rejection Ruining Your Day?
Looking at the aging insurance claim report, you spot a few secondary claims that remain unpaid and there are several claims that are aging past thirty days. You know there is something wrong. If you received a denial of payment on any claims, those have to be addressed immediately to get paid. Time is not on your side as accounts receivables start to rise and claims that age past six months are subject to non-payment by many insurance companies. This can happen quickly when you file secondary claims.
In the course of the dental business day, patient, staff and doctor concerns are priority and the phone is ringing in its constant interruptive way and cannot be ignored - but unpaid claims are the source of revenue necessary to cover the overhead and must be included in the priority task list for each day. Delegate someone to answer the phone so you can make five calls a day on unpaid claims to keep the system healthy. If claims are submitted correctly there should be few to follow-up on, but in some practices with untrained business staff the aging insurance report is several pages long and now will take hours, days or months to clean up - and that is if you know what you are doing.
Coding, documenting and filing claims correctly are subjects too vast to cover in this article, but let’s look at some basics. If you are doing electronic claims with electronic attachments, make sure this is set up correctly with your software provider. All claims going out to insurance companies should be billed with the standard fee schedule whether in or out of network. Check the claim verification reports after claims are sent to make sure there are no rejected claims. When sending attachments you will have an assigned number for those attachments for future reference.
Learn the insurance terminology to understand how payment is determined. For instance, do you know the difference between the “billed charge” and the “allowed charge”? The billed charge is the amount billed by the provider of services (standard fee schedule) directly to the insurance company and is reduced by the claim payment system to the allowed amount, or contracted rate negotiated by the insurer and its network provider. If you are not a network provider the patient will have to pay the difference between the insurers allowed amount and the amount that the provider charges that exceeds the allowed amount unless there is an agreement otherwise.
The allowable amount is the maximum dollar amount that an insurer will consider reimbursing for a covered service or procedure. This is also referred to as “maximum allowable amount.” The dollar amount may not be the amount that is ultimately paid to the member or provider as it may be reduced by any co-insurance (co-pay) deductible or amount beyond the annual maximum.
When a patient is covered by more than one dental benefit policy, the term “coordination of benefits” applies. This can change from one insurance company to another so it is important to determine correctly which plan is in the primary position. This can get complicated when a married couple have their primary plans and are also covered by each other’s plans and the children are covered by both. The primary plan must be billed first and when it is paid the Explanation of Benefits (breakdown of payment) is then copied and sent along with the secondary claim so payment may be determined. The documentation sent with the primary plan must also accompany the claim. The secondary insurer’s reimbursement, if any, takes into consideration any outstanding dollar amounts for covered services received up to the allowed amount. In any case, the secondary plan will never pay more than they would have paid had they been primary.
In researching claim denials the reasons can be as simple as wrong date of birth, missing relationship to provider, no subscriber ID or wrong social security number. Check all fields in the claim body to make sure information is correct. Other mishaps concerning improper coding can cause your claims to be red flagged by the insurance company. Remember that a miscode of a procedure may be innocent, but from the insurance company's view it can represent fraud. Relying on the business staff to choose the right code for what was performed clinically can lead to errors in claim filing and subsequent claim denials.
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