9.25.15 Issue #707 info@mckenziemgmt.com 1-877-777-6151 Forward This Newsletter

Belle DuCharme, CDPMA
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Insurance Denials and Appeal Process
By Belle DuCharme, CDPMA

“Justice is the insurance which we have on our lives and property. Obedience is the premium which we pay for it.” - William Penn

Dear Belle,
I just hired a new Insurance Coordinator after terminating the prior person for poor performance. I received some shocking news – there are literally thousands of dollars in claims that were not paid because the insurance companies did not receive them, and now the time is up for submitting the claims. I had no idea. What can I do?
Dr. Shocked

Dear Dr. Shocked,
With the help of your new Insurance Coordinator, investigate each claim for reasons why they were denied, because there can be many. If the insurance company is denying the claim because it wasn’t received, it could have gone out electronically but something was wrong on the claim so it never made it to the Clearinghouse. You would be able to check your rejection claim reports for the dates of submission. You may have to get help from your software support. Your previous Insurance Coordinator may not have checked this report and corrected the problems on the claims and resubmitted them. 

Every insurance company has a timely filing date that can be as little as 90 days or up to two years. Some insurance companies are willing to process legitimate claims beyond this date on a case-by-case basis. It is necessary to appeal these claims and I would appeal all of them.

If claims did get to the insurance company and you received a denial EOB but the claims were never followed up on with a timely appeal, these need to be addressed also. There are many reasons for denials, but most denials can be appealed with success if you follow the insurance company’s stated appeal process. Often, the insurance company received the claim but it was not adjudicated in a timely fashion, causing the denial based on timely filing.

Please see below a basic template letter form to edit and use to appeal for timely filing. Using the excuse of an employee’s poor performance or lack of knowledge may be a flimsy reason, but if your practice was hit with a weather disaster like a tornado, hurricane or earthquake that shut the practice down or a personal illness or Insurance Coordinator’s illness, this could be valid for reopening a closed claim. Reaching out to the insurance company on behalf of the patient is an excellent reason because the patient is looking to the practice to file correctly. Appealing the claims is the best course of action.

Letter Template:

Name of Insurance Company
Address (get address for appeals if it is different for claims)

Re: Appeal of Denial for Timely Filing.

Patient Name:
Group Number:                       DOS:
Subscriber No:                        Reference No.: (EOB#)

(Name of dentist or practice) is appealing the filing deadline for the following claim (claim #) for (patient name) and request that these claim(s) be reviewed and paid.

On (original submission date or DOS) we submitted claims for services rendered to the above patient. This was well within your timely filing deadline. (Or, if any other reason beyond your control caused the delay in billing such as provider illness, weather disaster, fire, burglary etc., document here.)

The promptly and properly submitted claims were neither paid nor denied by your company. On (date of resubmission) we resubmitted the claims for consideration. On (date of denial) we received a denial of the claims for “timely filing”. Please see the attached EOB from your company. 

I have attached copies of the original claims showing the date they were printed. Our office policy is to send all claims on the date they are produced. The printed date is the date of submission and is well within your deadline. Or: I have attached a copy of our Claims Submittal Report provided by our electronic claims clearinghouse showing that the original submission date was well within your deadline.

We respectfully request that these claims be promptly processed and that our office is paid for the services rendered to your subscriber as allowed by the State prompt payment regulations. 

If you have any questions, you are welcome to contact me directly at (phone number or email).

Practice Administrator Name (Title)

Don’t leave your hard earned production on the insurance denial table! For further instruction, sign up for a Business Training Program with McKenzie Management’s experts.

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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