Dental Insurance for Dummies
In the world of practicing great dentistry, dental insurance shouldn’t be a game changer. However, it carries heavy weight in the patient’s perception of whether or not to have dental work completed. Even though the maximums (for the most part) hover around $1000 to $1500, and have remained the same since the inception of dental insurance in the late 1960s, the statistics of patients seeking dental care are about 70% more than those without dental insurance.
If you are fee-for-service but accept assignment of benefits for all PPO insurance, you still have to play the insurance filing game correctly or you will lose patients. Your Business Coordinator or Insurance Coordinator is expected to be the “expert” - but he/she should never imply to be anything but a mouthpiece for what the insurance company has communicated about the patient’s eligibility and coverage. The following is a list of important information necessary to file claims correctly:
1. Update your software, because that is the source of updated CDT (Current Dental Terminology) codes and changes in the claim format. Without these updates, claims will be denied.
2. Accurate coding is mandatory or you will raise flags of possible fraud with the insurance company and lose the trust of your patients. Choose the code that best identifies the intended procedure that was or will be performed. If a code does not exist to accurately describe what was performed, use the 999 code matching the category and a clearly written narrative. Submitting 999 or miscellaneous codes without a narrative usually results in non-payment
3. When creating a narrative, you must verify that the doctor’s clinical notes support the narrative. If they are vague, clarify the procedure with the doctor or hygienist.
4. Narratives are required of many procedures and especially necessary when the x-ray does not support the procedure. For instance, if the existing composite restorations are washing out and exposing dentin, this may not be picked up in an x-ray. Narratives should be brief and concise and contain the words from the clinical diagnosis such as fracture, recurrent decay, pain to loading, decay at margin undermining existing crown, etc.
5. The more accurate information provided the cleaner the claim and the faster it is paid.
6. Don’t use a stamped or template narrative, as this is often thrown out by consultants.
7. The smallest detail can prevent a claim from getting into the insurance system, even if it made it there electronically.
8. Make sure you have the correct name of the patient as it appears on the insurance eligibility, no nicknames. Correct name and spelling of the subscriber. Correct address. Correct date of birth. Correct gender. Correct relationship to subscriber, such as spouse, self, child, dependent, or other. Correct group number and employer. Correct subscriber identification. Some insurance companies still accept the social security numbers but would rather have the subscriber ID. Some will not accept the social security number, putting your claim in the denied pile.
9. Indicate the number of x-rays you are sending on the claim and other documentation.
10. Indicate the initial placement of a crown or prosthesis. If replacement, you must have a date of prior placement. Ask the patient to try and remember and let them decide on a date. The narrative must include reason or replacement.
11. The treating doctor and billing doctor information must be accurate. If you have added an associate or have moved the practice, updating the credentialing is mandatory or payments will be denied or sent to the last address of record.
12. Authorization for signatures on file must be explained to the patient so it is understood that the payment on the claims is coming to the doctor.
13. If there is a secondary claim involved, checking eligibility to confirm which plan is primary will solve delay in receiving primary benefits. After receipt of primary benefits, the explanation of benefits or EOB must accompany the secondary claim.
14. For prosthetics, determine whether the claim will pay on the preparation date or the seat or cement date. When doing a Cerec crown the preparation and seat date are the same due to the one appointment process.
15. When doing electronic attachments, make sure they are labeled correctly. Check for accuracy of the x-ray, such as being able to see the apex of the tooth for a final root canal record.
These are key points, but this list is not complete. Remember that if your claims are not paid in a 30 day window, something is wrong and you must investigate.
Learn more by calling McKenzie Management today and sign up for our Professional Business Training Program.Forward this article to a friend
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