3.4.11 Issue #469 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Belle DuCharme CDPMA
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Are You Getting Reimbursed? Dental Insurance for 2011
Belle DuCharme, CDPMA

“If we aren’t reimbursed, we just write it off. We are busy enough that we don’t need the hassle of getting our patients mad and frankly it takes too much of my staff’s time chasing after unpaid claims.”  Dr. J. Hadenough

Not every practice can boast that it is busy enough to write off insurance money that is due them. The insurance industry will pay eligible claims, but only if we follow the rules in the insurance billing process. Often training is lacking at the front desk, which allows thousands of dollars to go unpaid annually. Claims that are initially rejected by the insurance company, more times than not, are collectable if follow-up is performed immediately. If the follow-up still does not result in payment, then get the patient involved either with a three-way call to the insurance company or by including a letter from the patient addressed to a specific insurance adjuster (ask for the person’s name who will be reviewing the claim).

The reimbursement process is a sequence of interdependent steps that start with the dentist’s service to the patient. The following is the outline of this important process.

Reimbursement Process

  1. With the initial contact on the telephone, collect the complete and accurate information from the patient and verify eligibility and coverage prior to the patient’s arrival in the practice. Name of subscriber and subscriber ID or SS#, DOB, name of employer, group number, name of insurance company and location to bill claims even if you send electronic claims, name of the patient and relationship to subscriber, their DOB.
  2. The exact service performed on the patient.
  3. The documentation of the service. This should be extracted from the clinical notes in the chart.
  4. Translate the service into billable CDT code.
  5. Charge onto patient’s record.
  6. Submission of claim either electronically or by mail or fax.
  7. Claim review by insurance company.
  8. Payment to the provider or the request for additional information for the carrier to be able to make a decision as to whether the claim is payable under contractual guidelines.  Requested information is often x-rays, narratives, periodontal charting or other records.

Lack of information that often holds up claim processing is:

  • Student status for patients age 19-26
  • Secondary insurance that is billed as Primary Coverage or vice-versa
  • Incorrect subscriber ID or using SS# incorrectly as Subscriber ID
  • Insurance company has record of other coverage for claimant
  • Group number missing or incorrect
  • Incorrect payer ID on electronic claims
  • Discontinued or incorrect CDT codes
  • Fee column is blank
  • Proper documentation, x-rays, narratives and perio charting

The dental record is a legal document, and services rendered should be accurately described and legible on paper or precise in the clinical notes area of the software system you are using. The rules for documentation are clear when it comes to billing to an insurance company. If the service is not documented with the elements necessary to justify the CDT codes, then the work should not be billed to the insurance company. The services rendered need to include the diagnosis and any special circumstances that may have occurred, along with the correct date of the service. For instance, if the patient was seen as an emergency on Saturday and you are posting the service the following Monday, make sure that the date of service is Saturday.

Often, it takes an experienced or trained billing coder to catch and correct claims so that they are paid. One claim was rejected because a crown was performed on a 3rd molar. The insurance company did not pay for restorations on 3rd molars, because they are usually extracted or out of alignment. However, when the insurance coordinator resent the claim, she included x-rays showing that the 3rd molar in question was in occlusion and a narrative explaining that the tooth had excellent bone and was a necessary tooth for the patient to chew food. The claim was paid at the contractual rate of 50% of the UCR fee.

Dental insurance benefits are an excellent source of cash flow, with very few problems associated with reimbursement if you provide the information necessary to expedite the claim. Need training to improve your reimbursement rates and increase cash flow in your practice? Sign up for a training course through McKenzie Management and we will give you the tools to succeed.

If you would like more information on McKenzie Management’sTraining Programs  to improve the performance of your team, email training@mckenziemgmt.com

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